A simple method to enable patient-tailored treatment and to motivate the patient to change behaviour

Abstract

In clinical practice and in self-management studies it appears that it is very difficult to change behaviour in patients with chronic obstructive pulmonary disease (COPD) in order to achieve adequate self-management. In this respect the role of motivational processes is underestimated and rarely is specifically targeted in interventions. In this article, the fundamentals of motivational processes are discussed followed by a detailed description of the Nijmegen Clinical Screening Instrument (NCSI) method. The NCSI method is a simple method that enables patient-tailored treatment and to motivate patients to adhere to treatment goals. The NCSI method consists of three distinct but highly integrated components: (1) a short instrument measuring many details of health status; (2) an intervention that helps to identify individual treatment goals and to motivate the patient to change his behaviour; (3) an automated monitoring system that simply identifies patients with new problems in health status of self-management. All components are embedded in a web-based application which enhances simplicity, efficiency, and effectiveness of the NCSI method. The NCSI method is illustrated by a case study.

Introduction

Do you recognise this patient from your clinical practice? Mrs Smith is 48 years old and is diagnosed COPD GOLD II (FEV₁ = 55% predicted). Her body mass index is 18. She still smokes and does not do any sports activities. Although she reports fatigue, she states not to have any problems: ‘everything is fine’. Despite frequent discussions, you did not succeed to motivate her to quit smoking. Because she does not perform any sports activities (too fatigued), you suspect poor physical fitness. Considering this, in combination with her underweight, you discussed the option of a pulmonary rehabilitation program with her, but she refused. This deadlock continued for several years.

From a clinical perspective several questions arise concerning Mrs Smith. Are disturbed lung function, underweight, and fatigue the only impairments in her health status? Why does she refuse to adopt adequate health behaviours or to engage in pulmonary rehabilitation? What will be the long-term consequences of this? Is poor physical fitness the cause of her fatigue? Do you really know whether ‘everything is fine’? To lift a corner of the veil in advance: no, nothing turned out to be fine.

This article describes the Nijmegen Clinical Screening Instrument (NCSI)-method, an evidence-based and simple approach that broke the deadlock in the treatment of Mrs Smith and offered answers to the clinical questions described above. This approach has three central elements: (1) a simple web-based assessment instrument applicable in usual care, which provided the caregiver with a detailed picture of Mrs Smith’s health status;  (2) a simple intervention, which elucidated the mechanisms underlying the problems in her health status, and which motivated her to engage in a pulmonary rehabilitation program (including smoking cessation); and (3) an automated monitoring system.

Self-management and motivation to change behaviour

Chronic obstructive pulmonary disease (COPD) is a common, preventable and treatable disease, is characterized by persistent airway limitation that is usually progressive and is associated with an enhanced inflammatory response in the airways and the lung to noxious particles or gasses. ¹ Exacerbations and comorbidities contribute to disease severity in individual patients. Patients with COPD not only have physiological disorders but also may experience symptoms, functional impairment, and a diminished quality of life. Many studies have shown that the severity of symptoms, functional impairment, and quality of life are poorly related to the severity of the physiological disorder. ^{2 –4} These three domains are determined not only by disease activity but also by the degree to which the patient has adequately adapted to his illness. Examples of adequate adaptation are adherence to medication regimens, exacerbation management, adopting a healthy life style (regular exercise, dietary intake, smoking cessation), energy-saving strategies, breathing regulation, stress management, and so on. It is imperative to note that all these aspects of adaptation to the illness require behaviour change by the patient. ⁵ Even the typical physiological goals such as increasing physical fitness require structural behaviour change by the patient. For example, if a patient has improved his or her physical fitness in an 8-week training program, then goes home and returns to a sedentary life style, his or her physical fitness will decrease very quickly. Mrs Smith obviously shows poor adaptation with respect to regular exercise and smoking. However, as we will see later, she showed other and more prominent aspects of poor adaptation, which resulted in severe impairments in her health status.

Many interventions have been designed to teach the patient adequate self-management in order to achieve optimal adaptation to the disease. However, many patients like Mrs Smith are unwilling to participate in such programmes in the first place ^6,7 and the effectiveness of these programmes is disappointing. ⁸ Thus, motivating patients to change their behaviour or to enrol in a self-management intervention programme appears to be difficult. In fact, poor motivation sometimes is considered a key characteristic of patients with COPD. ⁹ Caregivers often experience the process of achieving adequate self-management in patients with COPD as difficult and frustrating due to the fact that patients are very unwilling to change their behaviour. In daily practice, it occurs that the caregiver ‘gives up’ on the patient.

However, high motivation to change behaviour is not a trait of a patient but is the end result of a process within that patient. Therefore, increasing motivation should be one of the first steps to take in any intervention. When looking more closely at the content of self-management interventions, specific interventions to achieve high motivation are often lacking. ¹⁰ Moreover, many caregivers by nature are ‘problem solvers’. This attitude of the caregiver may be an important reason why we as caregivers do not take the time to question whether the patient agrees with us on the problems we see and the solution we offer. To put it bluntly, in daily practice it is common that the caregiver tells the patient he or she has COPD and therefore he or she has to quit smoking, start regular exercise and change his or her dietary habits. The patient very often does not accept these goals and most certainly does not change his or her behaviour. So how can this be explained?

Let us first look at the fundamentals of motivation to change behaviour. The key issue for motivation to change behaviour is ‘what will be the benefit of this behaviour for me?’ In COPD, the desired adaptive behaviours mean that the patient has to give up behaviours that have a positive value for him or her (e.g. smoking) and has to adopt behaviours that are very unattractive to him (e.g. regular exercise). So, apprehending the personal benefits of the new behaviours (which is the prerequisite for motivation to behaviour change) for most patients is a long way to go.

The grieving process and motivation to change behaviour

As the disease progresses, patients are increasingly confronted with many experiences of loss (e.g. health, independence, work, hobbies, and social activities). This triggers a process of mourning, which initially is characterized by denial or trivialization of complaints, followed by resistance, sadness and eventually acceptance. COPD is a progressive disease that starts very mildly and evolves slowly. Complaints or impairments then for many years can be attributed to ‘normal’ causes, such as age or being in a bad physical condition, can be ignored or trivialized. This typically is the situation in the stage of denial. In the stage of resistance patients are fully aware of the seriousness of their problems in health status but are frustrated that they cannot continue many normal activities and increasingly have to give up activities or hobbies. These patients struggle to maintain their activities and therefore do not change behaviour to achieve optimal adaptation to the disease. The stage of sorrow is characterized by sadness and passivity. Acceptance, in fact, is the end stage of the grieving process in which the patient has given up denial, resistance, and sadness. In reality, of course, these stages are not clear cut but may overlap in time. Also, the time in which a certain stage is predominant may be very different for each patient. Especially the stage of denial can take many years and may be a cause why the patient does not visit his general practitioner in the first place. As losses occur over the years the grieving process the patient may experience multiplies. In Table 1 an overview is presented of the different stages and their related core cognitions (key thoughts), emotions and behaviours.

Table 1.

Stages of the grieving process in COPD and related core cognitions (disease-related ideas/attitudes), emotions and behaviours

Stage	Core cognition	Emotion	Behaviour
Denial	‘I have no problem’	Neutral	No adaptive behaviours
Resistance	‘I want my normal life back’	Frustration	No adaptive behaviours, even maladaptive behaviours
Sorrow	‘All is hopeless’	Sadness, despair	Passive, no adaptive behaviours
Acceptance	‘If I adapt to my disease I will have less symptoms and better quality of life’	Neutral	Performing adaptive behaviours

The grieving process may complicate the motivation process. Patients in denial do not experience any problem (whether or not there is a problem) and therefore are not willing to adopt any unattractive new behaviours. Patients who predominantly are in the stage of resistance want to reinstall their normal activities. Patients who predominantly are sad mainly are passive, as they see no hope in any improvement.

Increasing motivation to change behaviour: motivational interviewing

From two psychotherapeutical main streams (client-centred therapy and cognitive-behavioural therapy), techniques can be derived, which are effective in increasing motivation to change behaviour. One of these is motivational interviewing. ¹¹ In its essence motivational interviewing attempts to increase a person’s awareness of the potential problems of his or her actual behaviour and to change his or her thinking of this behaviour to ultimately consider what might be gained through change (creating a discrepancy between what you are and what you want to be). In COPD this often means that the patient has to become aware of the severity of his or her disease, of his or her problems in health status, and the negative effects of his or her maladaptive behaviours. Motivational interviewing originally was developed to treat substance abuse but also has been found promising to increase health behaviours in chronic diseases. ^12,13 There are few studies on motivational interviewing in COPD, mostly related to smoking cessation.

Motivational interviewing requires specific skills of the caregiver. First of all, the caregiver has to express empathy, which means that the caregiver can express to the patient that he or she can see the world through the patient’s eyes in a nonjudgmental way. Expressing empathy is crucial as the patient feels understood, which has the effect that the patient will be more open to explore his or her behaviour and consider alternative behaviours. The caregiver does not fight resistance, but “rolls with it,” because challenging resistance increases resistance. The patient is responsible for choosing his or her behaviour, the caregiver supports the patient in this respect. The main goals of motivational interviewing are to establish an active interaction between the patient and caregiver, establish a discrepancy between his or her actual behaviour and his or her desired behaviour, elicit ‘change talk’, and to achieve commitment from the patient.

The techniques by which this can be achieved depend on the attitude of the caregiver: motivation is elicited from the patient, not imposed upon by the caregiver; it is the patient’s task to change behaviour, not the caregiver’s; persuasion is not effective to change behaviour, although the caregiver should be directive in guiding the patient to examine and resolve the discrepancy between his present behaviour and alternative adaptive behaviour. The caregiver thus operates as a coach.

Assessment issues

The case of Mrs Smith certainly is not an exception. Many patients experience problems in health status but are poorly motivated to adopt adequate health behaviours or to enrol in self-management programs, such as pulmonary rehabilitation programs. However, the root of the problem not only lies in the patient, professionals also play a significant part in this.

The phenomena ‘patient delay’ and ‘doctor delay’ are well-known causes of underdiagnosis in COPD. The same phenomena are to a major part responsible for underdiagnosis of problems with respect to complaints, functional impairment, quality of life, and self-management. The doctor underestimates these problems (doctor delay) and the patient does not present these problems or is not motivated to adopt adequate health behaviours resulting in poor adaptation to the illness (patient delay). The phenomena doctor delay and patient delay may leave problems in symptoms, functional impairment, quality of life, and poor self-management unidentified and untreated. In many patients this may lead to escalation of these problems. Mrs Smith is clearly at least at risk in this respect.

Doctors are by their profession primarily focused on the physiological disorders. In addition, complaints, functional impairment, and quality of life are highly subjective phenomena and are therefore very difficult to evaluate during a routine visit. In the case of Mrs Smith, the doctor revealed airway obstruction and underweight. Besides fatigue, no problems in other complaints, functional impairment, or quality of life became apparent.

With respect to patient delay, the grieving process and motivational factors play a crucial role. Mrs Smith was not motivated to adopt adequate health behaviours (smoking cessation and regular exercise), was not motivated to engage in a pulmonary rehabilitation program, and did not report any problems besides fatigue. What her specific impairments in health status were, and why she was not motivated we will find out later in this article.

The Nijmegen clinical screening instrument (NCSI) method

To summarize thus far, assessment and treatment should focus not only on the physiological disorders but also on symptoms, functional impairment, quality of life, and adequate adaptation (i.e. self-management). In clinical practice problems in these domains often are not identified by the caregiver and the patient does not present these problems or is not motivated to deal with these problems. Moreover, patients may be very different in the type and severity of problems they may experience. But even if a patient has adopted adequate adaptive behaviours, at some point in time these adaptive behaviours may fade away or may not be adequate anymore. The latter situation may be caused by disease progression or life events such as a partner who needs support, a divorce, and so on. Such new problems should be identified as early as possible. Therefore, a patient has to be monitored for the rest of his life. Thus, what we need in clinical practice on the level of the individual patient is:

an instrument suitable for use in clinical practice that helps to identify problems in health status and poor adaptation/self-management;

an intervention that helps to analyse the underlying causes of these problems;

formulating treatment goals tailored to the needs of the individual patient;

motivating the patient to change behaviour; and

regular monitoring of the patient.

Considering the above, we set out to develop a simple method that helps the caregiver to achieve all these goals in one or two sessions. The method should be short to warrant application in any usual care setting and must give guidance to caregivers with little experience in applying principles of motivational interviewing in patients who may experience complex problems in health status and adaptation. The NCSI method consists of three different but highly integrated components:

• Detailed assessment of health status: NCSI (requirement 1)

• The NCSI intervention aimed at formulating individualized treatment goals and on motivating the patient to change behaviour (requirements 2-4)

• The NCSI monitoring instrument to enable simple and automated regular monitoring (requirement 5)

The NCSI assessment method

General theories define health status as an overall concept covering physiological functioning, symptoms, functional impairment, social functioning, and quality of life as main domains. ^14,15 These main domains were found to be subdivided into many more concrete subdomains. ^16,17 In addition, these subdomains were shown to be relatively independent of each other, which means that each subdomain describes a unique aspect of a patient’s health status.

The NCSI was specifically developed to be used in routine care on the level of an individual patient. The NCSI is short enough to be used in routine care (approximately 15 min to complete), but measures 8 aspects of symptoms, functional impairment, and quality of life. ¹⁸ Clinical applicability was further enhanced by the development of computerized questionnaire software (RadQuest) and rendering patient scores clinically meaningful. RadQuest was developed by the Department of Medical Psychology and the Department of Instrumental Services of the Radboud University Nijmegen Medical Centre. Questionnaires are presented in the same layout as the paper-and-pencil version, items cannot be skipped, and scoring and data storage is automated. The software is web-based which enables questionnaire completion at home. The most important feature is the automatic production of the PatientProfileChart (PPC). The PPC offers a visual and therefore easily interpretable picture of the integral health status of an individual patient. See Figure 1 for an example of the PatientProfileChart of an individual patient. Each column represents the score range for each subdomain. The ‘•’ represents the score of an individual patient. The score range of each instrument also is divided into coloured ranges, which allow absolute interpretations. The green score range indicates ‘normal functioning’, the yellow score range indicates ‘mild problems’, and the red score range indicates ‘severe problems’. ¹⁸ The PatientProfileChart very clearly shows to the caregiver and the patient in which areas of health a patient experiences no problems and in which areas he or she does experience problems and how severe these problems are.

In a later stage, we developed the Acceptance of Disease and Impairments Questionnaire (ADIQ). This questionnaire is a valid measure of the stages of the grieving process denial, resistance, sorrow, and acceptance (submitted).

Motivating the patient: a simple intervention by a pulmonary nurse

In its essence the intervention entails discussing the PatientProfileChart with the patient and partner. The pulmonary nurse first explains how to read the PatientProfileChart and then goes through each column. The patient is frequently asked whether he or she recognises himself or herself in the results. The same holds true for the partner. Also, questions aimed at elucidating the underlying causes of the specific problems in health status are asked. The PatientProfileChart makes it very simple for the patient and for the caregiver to actually see the severity and the type of problems a patient experiences.

This procedure takes approximately 30 minutes and has two major effects:

The underlying inadequate adaptation behaviours become clear. This is a crucial information for formulating treatment goals. Problematic scores with respect to symptoms, functional impairment or quality of life can have many different causes and therefore may require totally different interventions. For example, if a patient has high score on depression because he or she cannot handle his or her dyspnoea this would require a totally different intervention than when this depression score would have been caused by marital problems.

This intervention has proven to be very powerful in motivating patients to enrol in a self-management program or even in a multidisciplinary inpatient pulmonary rehabilitation program. In its essence there are three underlying processes to achieve this:

The patient becomes highly aware of the type and severity of his problems.

It becomes very clear to the patient how his own behaviour contributes to these problems.

The treatment goals are logical consequences of the previous points and in this respect gain personal relevance (the prerequisite for motivation to change behaviour).

This intervention addresses in a simple way the core of increasing motivation. In fact, this intervention is an aid for the caregiver to adequately and quickly perform motivational interviewing. In particular, the intervention makes it very easy to achieve in a very short time the two key aims of motivational interviewing: creating a discrepancy and dealing with resistance. These aims are not only the most crucial but also are the most difficult to perform and normally require great expertise and skills.

With respect to creating a discrepancy, problems in health status are presented visually by the PatientProfileChart, which has much more impact than words. Discussing the causes of these problems makes it very clear to the patient what the personal benefits of the new adaptive behaviour will be as contrasted to the negative effects of his or her current behaviour.

With respect to dealing with resistance, in motivational interviewing the caregiver has to ‘roll’ with resistance in order to lower resistance, and thereby opening the patient to explore his or her current behaviours. In the NCSI intervention this simply is accomplished by the fact that his or her problems in health status are visible on the PatientProfileChart and are the resultant of the responses of the patient himself. Any expression of resistance simply can be handled by pointing to this fact. Another important aid in this respect is the Acceptance of Disease and Impairments Questionnaire (ADIQ). On the PatientProfileChart the scores on denial, resistance, sorrow, and acceptance are visible. The caregiver only has to point to these scores and invite the patient to elaborate on these scores.

Similar to motivational interviewing, the attitude of the caregiver is empathic and nonjudgmental. Also, the caregiver makes the patient an active participant in the interpretation of results and the formulation of goals as much as possible, by asking questions instead of giving interpretations or advice. This increases commitment from the patient with the final treatment goals.

Finally, this process should lead to the formulation of individual treatment goals. In the NCSI-intervention the procedures is as follows:

After discussing the PatientProfileChart the patient is asked what he thinks of all this. Very often patients are startled and emotional.

Then the patient is asked whether he or she wants to change the situation visible on the Patient ProfileChart. The patient then is invited to say which problem in health status he or she wants to improve. For example, the patient wants to become less fatigued and dyspnoeic in order to be able to go fishing again.

When the patient has selected one or more problems, he or she is invited to explore together with the caregiver what is needed to achieve these personally relevant goals. Considering the example above, smoking cessation, increasing physical fitness, and applying energy-saving strategies may be required.

The major difference with common practice in usual care and the NCSI procedure is that in usual care unattractive treatment goals, such as smoking cessation or regular exercise, are presented as the final goals. Within this context, the patient does not see any personally relevant benefit. In the NCSI method, these treatment goals are put into a context in which these behaviours are not the final goals but merely the means to achieve personally relevant benefits (less fatigued, dyspnoeic, and going fishing again).

The patient takes the PatientProfileChart at home and is encouraged to discuss results and conclusions with his partner. All these aspects increase awareness of the severity of the problem, increase motivation of the patient (and partner) with the treatment goals, and break through natural defence reactions such as denial/trivialization or resistance, and eventually achieve structural behaviour change. This very simple procedure takes about 30 minutes but has powerful effects.

The NCSI method in usual care: Mrs Smith revisited

The pulmonologist referred Mrs Smith to the pulmonary nurse with the question to analyse her situation and to motivate her to quit smoking. The anamnesis by the pulmonary nurse provided additional information. Mrs Smith was married, with two adult children. She worked three mornings and one whole day as a housecleaner. She found her work tiring, but in general she did not experience functional impairments in her daily life. Because of her work she was too tired to do any sports activities. She was very explicit in her refusal to quit smoking. When asked, Mrs Smith indicated not to have any goal in reference to her disease.

The NCSI method: assessment

The personal PatientProfileChart of Mrs Smith is presented in Figure 1. The ‘•’ represent her scores. Inspection of the PatientProfileChart reveals the following. Main domain Physiological Functioning: airflow limitation between 50% and 60% of predicted and underweight. Main domain Complaints: extreme fatigue and severe dyspnoea severity, dyspnoea burden, and dyspnoeic when physically active. She is not anxious when dyspnoeic, but her frustration level is at the verge of ‘severe’. Main domain functional impairment: there are no behavioural impairments with respect to activities at home or when walking. On the subjective level she experiences mild impairments. Main domain quality of life: she is not depressed, but her satisfaction with life in general is severely disturbed. She is dissatisfied with her physical functioning but has confidence in the future and is satisfied with her social functioning. The grieving profile on the ADIQ is remarkable; high levels of denial, even higher levels of resistance, a moderate level of sadness and a low level of accepting her illness.

Figure 1.

PatientProfileChart of Mrs Smith. The green score range indicates ‘normal functioning’, the yellow score range indicates ‘mild problems’, and the red score range indicates ‘severe problems’. n.a.:not available; dysp.: dyspnoea; subj.: subjective; accep:  acceptance; •: pretreatment scores; X: posttreatment scores.

NCSI method: the intervention

The pulmonary nurse discussed the PatientProfileChart with Mrs Smith and her husband. Mrs Smith recognized the profile and became very emotional. She admitted that for the first time she was open and honest. Until then she trivialized and concealed her complaints. She stated that she was not fatigued but was exhausted. She indeed did not have any functional impairments, because she continuously overexercised (in particular with respect to activities at home and at work). This turned out to be the major cause of her extreme fatigue. Her frustration was the result of her perfectionism in relation to the problems she encountered in her daily activities. Her husband was astonished; he did not know that the situation was that serious. The final treatment advice (inpatient pulmonary rehabilitation) logically followed from the discussion of the PatientProfileChart. The discussion of the PatientProfileChart was very confronting: the strong trivialisation and denial was broken. She agreed with the pulmonary rehabilitation program, including smoking cessation.

Mrs Smith in multidisciplinary inpatient rehabilitation program

During the rehabilitation program, Mrs Smith did not gain in weight and did not improve in physical fitness. This may be explained by two exacerbations she experienced during the 12-week program. She was known for a low body weight all her life. She successfully learned breathing techniques (pursed lips breathing) and sputum evacuation techniques. She was more able to bring her daily activities in line with the constraints the disease posed on her. In this respect, she was more aware of her bodily sensations and, guided by these sensations, more often took a rest or reduced her pace, and allowed her husband to help in housekeeping activities. She quit smoking.

Her posttreatment scores on the PatientProfileChart are presented in Figure 1 and are depicted by ‘x’. She showed significant improvement with respect to fatigue severity, different aspects of dyspnoea and dyspnoea-related emotions and different aspects of quality of life. Regarding functional impairment she showed more impairment in activities at home. This was consistent with the treatment goal of allowing her husband to take over some of these activities. Also, her acceptance profile significantly changed: scores on denial dropped massively and scores on resistance dropped significantly. Acceptance improved a little. These major improvements in her health status thus did not occur because of increased physiological functioning but by the improved adaptation to her illness (adopting adequate self-management behaviours).

Regular screening of patients: NCSI monitor

Although the NCSI enables a quick assessment of health status, still it takes 15–20 min to increase quality and efficiency in clinical care and to help nonpsychologists to make a correct interpretation of the PPC, we developed an instrument that makes this conclusion automatically.

Analyses identified 8 items of the NCSI which together predicted through a mathematical formula whether or not a patient would show a deviant profile on the PatientProfileChart or not. In 91% of cases this formula correctly predicted the diagnosis of the psychologists. Sensitivity was 0.91 and specificity was 0.94. This 8-item instrument was called NCSI monitor.

Note that NCSI monitor is not a short version of the NCSI. The 8-item NCSI monitor only predicts whether a patient would have a deviant profile on the NCSI or not. What these problems are and what the causes of these problems are can only be elucidated by the NCSI instrument and the NCSI intervention. This instrument thus would be an ideal monitoring instrument. It enables a very quick and automated prediction of a patient at risk.

Comparison to other health status instruments and self-management interventions

When comparing the NCSI assessment instrument to other commonly used health status instruments important differences can be noted. The NCSI measures much more aspects of health status (Figure 1) than any other instrument. The St George’s Respiratory Questionnaire (SGRQ) ¹⁹ contains three subscales but was shown to measure only two distinct aspects of health status. ²⁰ The Clinical COPD Questionnaire (CCQ) ²¹ at best measures three aspects and the COPD Assessment Test (CAT) ²² only measures one aspect. The latter two instruments are shorter though. In addition, the NCSI is web-based, allowing completion of the questionnaire at home, has clinical meaningful scores based on normative data, and the scores and norms are presented automatically by the graphical PatientProfileChart, which makes interpretation of results very easy for the caregiver and for the patient.

Despite the strong qualities of the NCSI assessment, the NCSI method also contains an integrated intervention, which is by far more important than the assessment instrument by its own. The NCSI intervention helps to formulate individualised treatment goals and it motivates the patient to adhere to these goals and change his or her behaviour. Self-management programs in general educate the patient how to cope with COPD to achieve adequate self-management and thereby primarily are directed at the treatment goals. Specific interventions directed at increasing motivation to adhere to these goals and dealing with denial and resistance commonly are lacking. The NCSI method and motivational interviewing are alike with respect to the basic principles and communication techniques in achieving individualised treatment goals and increasing motivation to adhere to these goals. Motivational interviewing, however, heavily relies on the skills and expertise of the caregiver. In the NCSI intervention, the PatientProfileChart, and the structured way to discuss the PatientProfileChart provide much more guidance and structure to the caregiver. The PatientProfileChart provides a very simple but powerful tool for the caregiver to deal with denial and resistance. The latter two aspects explain why the NCSI method requires fewer sessions than motivational interviewing as a technique by itself. The NCSI method is only applicable in the stage of formulating treatment goals and increasing motivation of the patient. The subsequent treatment itself, that is executing the treatment goals, is out of the range of the NCSI method. Although the PatientProfileChart can be used in the treatment phase to maintain motivation, in this phase motivational interviewing and other behaviour change techniques are required.

Conclusion

Improving a patient’s health status requires not only improving physiological functioning, but also teaching the patient to adapt to his or her disease. The process of adaptation requires behaviour change by the patient. Even typically physiological goals such as increasing physical fitness require structural behaviour change by the patient. At present, common interventions described in guidelines such as the GOLD guidelines, do not appear to be effective to achieve behaviour change. An important reason for this may be the fact that the importance of behaviour change with respect to all treatment goals is underestimated. Moreover, the crucial role of motivational processes in this respect as well as adequate interventions to increase motivation is lacking altogether.

Motivational interviewing is promising to increase motivation to change behaviour in COPD in order to optimize adaptation to the disease. However, motivational interviewing requires expertise and skills from the caregiver and may take multiple sessions. The NCSI method was developed to be used in routine clinical care for an individual patient as an aid for the caregiver to formulate individualized treatment goals and help the caregiver to motivate the patient to adhere to these goals within only a few sessions. The NCSI method also can be used to evaluate treatment effects and to monitor the patient over the years in a very simple and automated way.