The Importance of Language in Behavior Change

Abstract

Communication between health care providers and patients is important for behavioral treatment in lifestyle medicine. Ineffective communication can lead to patient dissatisfaction, demotivation, and discontinuation of treatment. It is important for health care providers to understand their biases, praise patients’ behaviors rather than health outcomes, and use language to prevent dichotomous thinking. These strategies may lead to sustained lifestyle behavior changes and better treatment outcomes among patients.

‘Effective communication between health care providers and patients predicts treatment adherence and continuation.’

In recent years, there has been a general trend toward individuals seeking medical advice from online resources rather than from a health care professional. ¹ This may be due in part to people feeling judged by health care providers.^2,3 Turning to the computer for health care information avoids interaction with a health care provider and potential feelings of embarrassment. It is important that all health care providers establish a rapport with their patients such that patients feel comfortable sharing their health concerns. ⁴ The success of lifestyle disease treatment depends on a patient’s honesty and willingness to return for follow-up visits so that life-long care can be provided.^5-7 As discussed in this issue by Offringa and colleagues, ⁸ the language used in health messaging is a critical component to establishing patient rapport for successful outcomes. Words used by health care professionals can convey respect for patients as well as clinician biases, which either builds up or erodes patient trust. ⁹ Effective communication between health care providers and patients predicts treatment adherence and continuation.^10-12 Conversely, ineffective communication between the health care providers and patients can contribute to patient psychosocial distress, inadequate symptom management, and poor quality of life. ¹³ Stigmatizing beliefs and dichotomous thinking are two challenges to effective communication between health care providers and patients.

Stigmatizing Beliefs or Prejudice

One clear example of the importance of language in lifestyle medicine is found in the obesity literature. Social stigma and discrimination are common among individuals with obesity.^14-16 These biases have consistently been found to also be held by health care professionals.^17-19 Albeit unintentionally, health care providers’ stigmatizing beliefs and prejudices regarding weight status are conveyed through their word choices. For example, using the term “recidivism” when discussing weight regain suggests a moral judgment. ¹⁴ The word “recidivism” was originally used in reference to criminal behavior. Using it to discuss weight indicates a belief that the patient is solely responsible for the weight gain. This unintentionally conveyed bias may prevent the patient from returning for further treatment, decreasing the likelihood the patient will make health behavior changes. Word choices connoting judgement may also lead the patient to internalize stigmatizing beliefs about himself or herself, further decreasing the likelihood that the patient will adopt healthier behaviors.^20,21 Although the obesity literature provides a good example of health care provider bias, biases exist for patients across many sociodemographic characteristics and types of lifestyle diseases. Appropriate care requires careful attention to provider language to prevent bias from being conveyed.

The first step to improve provider language is to accept that everyone, including health care providers, hold biases. It is important for health care providers to recognize their own biases. This increased awareness will enable providers to be more mindful about their word choices and to intentionally avoid using words that convey judgment to patients. Conscious effort is required to change word choices initially, but over time the use of language that does not connote bias will become routine. Because biases may shift over time, it is important for providers to consistently reassess their biases and remain mindful about how their beliefs may unintentionally be communicated to patients.

The Issue of Dichotomous Thinking

Provider language can also promote or discourage dichotomous thinking. Dichotomous thinking, also known as “all-or-none thinking,” is a way of thinking in terms of polar opposites such as “black or white,” “healthy or unhealthy,” and “good or bad.” ²² This is considered a form of cognitive rigidity. Dichotomous thinking can often be identified by the words that are used by both patients and health care providers. Many patients already think in terms of extreme appraisals regarding health behaviors and outcomes, such as a “good or bad” diet, “acceptable or unacceptable” blood glucose level, and treatment “success or failure.” ²³ This type of thinking provides a narrow perspective and typically leads to negative evaluations of progress, which ultimately decreases motivation to continue lifestyle changes. The words used by health care providers can easily reinforce dichotomous thinking.

Dichotomous thinking among patients creates a barrier to behavioral change necessary for treatment success and is associated with increased risk of eating disorders and obesity. ²⁴ Despite the common grouping of foods into “healthy” or “unhealthy,” food choices do not fall into two mutually exclusive categories, and no one food or type of food is responsible for weight gain. This can act as a barrier to dietary adherence. For example, a weight management patient that eats a less healthy food might feel like she or he has failed in her or his diet for the day. This, in turn, may lead the patient to abandon her or his dietary plan and overeat. Rather than providing lists of food to eat and lists of foods to avoid, discuss foods in terms of being more or less healthy. Frequent use of terms that indicate a continuum instead of “good or bad” to describe health behaviors can be helpful to dissuade patients from an all or nothing approach. Similarly, using a statement like “more or less in line with your goals” when talking about behavior changes can help patients think more flexibly to sustain healthy behaviors. ¹⁴

Dichotomous thinking is also common among health care providers. This is particularly true regarding the determinants of health. The determinants of chronic health issues are multifaceted, caused by the interplay between and cumulative effects of a range of biological, environmental, social, and behavioral factors. ²⁵ However, this complex reality is more challenging to conceptualize than “black and white” thinking in which people believe one factor is the cause of a health condition. Two current opposing views regarding the causes of obesity are individual responsibility and determinism (the belief that health outcomes are predetermined and cannot be changed). ²⁶ In the past, most of the language surrounding obesity focused on individual responsibility and self-discipline, which led patients to feel blamed when weight loss goals were not achieved. A shift is occurring that makes it more likely for health care providers to also discuss genetics, epigenetics, environmental factors, and societal norms as reasons for difficulties in meeting weight loss goals. This is appropriate; however, the health care provider is cautioned to not focus “more heavily” on either type of information.

Biases on the part of the health care provider can lead to subtle judgements that are reflected in communication with patients. ¹⁴ A health care provider who believes that obesity is caused by personal maladaptive behaviors and a lack of self-control will convey the idea that patients are solely responsible for their obesity. Patients who feel blamed are unlikely to feel comfortable sharing information that would enable the health care provider to help them. Conversely, a health care provider that believes that obesity is determined primarily by genetics may communicate the notion that there is nothing the patient can do to improve his health, leaving the patient feeling powerless. It is critical that health care providers discuss challenges in making lifestyle changes that stem from both the responsibility of the individual and from factors that are outside of an individual’s realistic control. This approach mitigates the likelihood of dichotomous language being used regarding health outcomes.

Conclusions

Health care providers are encouraged to increase their awareness of their own biases and recognize dichotomous thinking in both their patients and themselves. Additionally, it is important for health care providers to make the focus of treatment be on patients’ behaviors, not health outcomes. Weight, blood pressure, cholesterol levels, and so on, are important markers of health to monitor. However, because these cannot be directly controlled by the patient, health behaviors that lead to improvements in health outcomes make better treatment goals.

Similarly, it is important to praise behaviors (eg, selecting healthier food options and being more physically active) rather than health outcomes. A patient that is consistently praised for weight loss each visit, instead of the behaviors that lead to weight loss, may feel like they have failed when weight loss does not occur, despite having adhered to physical activity and dietary prescriptions. Assurances that plateaus in weight loss or weight regain are “fine,” “common,” or “expected” can be confusing when only weight has been discussed previously. This can result in patient mistrust in the plan and may convey unintended judgements. For example, this type of language can reinforce a health care provider bias that obesity is caused by genetics, and no matter how hard a patient tries, he or she will not be able to successfully manage his or her weight. Instead, it is important for health care providers to explain to patients that weight loss is challenging. Some things are biologically (ie, genetics) or environmentally (ie, the high prevalence of tempting fast food options) out of a patient’s control. However, there are also many behaviors the patient can adopt to improve his or her health (eg, increase the availability of ready-to-eat, nutritious foods in the house, make time for physical activity each day, or monitor dietary consumption on a smartphone application). Focusing on healthy lifestyle behaviors instead of health outcomes can help keep both health care providers and patients from thinking dichotomously and improve long-term care of chronic disease.