Conviction and Confidence

Your words have the power to help patients succeed in making change, no matter your level of clinical skills. 

One of the most challenging roles of a diabetes educator is to help those who seem stuck - those unable to make a specific behaviour change, appointment after appointment.  What can help?

  • Assessing for conviction and confidence (first!)
  • Using strategies to increase conviction and confidence (second; the order matters)

Summary up front: As a generality, people are either NOT READY to change (left) or READY to change (right). Where they are determines the strategies you'll likely use to move them towards change. 

dcc convictionbedard 2019


dcc behavioural destinations 2018

Promoting behaviour change can be hard.  Some people won't look at a destination, never mind travel the road there. Others know their destination, but see roadblocks. There are strategies to help both. These include assessing and increasing conviction and confidence.

CONVICTION: A belief that something is personally IMPORTANT. 

CONFIDENCE:  A belief in that something can be personally ACHIEVED. 

Does your patient believe the change would benefit him? Does your patient believe she can make the change, even though she feels it's important?  Without assessing both, you could be wasting time for both of you. Or worse, you could be alienating patients.

Assessing and building conviction and confidence are a small aspect of Client Centred Counseling or Motivational Interviewing.  These types of counseling contain techniques to help patients move themselves toward behaviour change,  If you have the chance to take a course, please do. You’ll feel more capable of helping clients (and less frustrated) - as will they! 


Assess for Conviction

Consider these questions when assessing how important a patient finds a specific behaviour change. Try not to interpret a patient's smiles, long-standing relationship with you or their lack of dissent as high conviction. Clarifying conviction levels with direct questions is respectful of the patient's preferences, time and efforts. Allowing time for the patient to think and reflect outloud can provide insight into a patient's beliefs about a behaviour, concerns, expectations and ideas about how that behaviour change may impact their life.

  • "How do you feel about ____(insert behaviour)?"
  • "How do you think ____(insert behaviour) will benefit you?"
  • "On a scale of 1 to 10 how important is ____(insert behaviour) to you?" 

You may need to assess "Higher Up" by asking:

  • "How important is getting lower glucose levels to you?"
  • "How would a lower A1c impact your dreams for home, work, family?"
  • "How would you feel about making medication changes if it could reduce your risk for _____(e.g. kidney or eye damage. Insert the specific complication you feel best connects with the patient)?"

ahs conviction scale vs smile 2018

Levels of Conviction

Low: 0 - 3

  • Patient lacks knowledge, lacks personal reason or doesn’t truly believe they are at risk if the  behaviour is left unchanged.  E.g. “My grandfather smoked till age 93 and never had a heart attack. I'd be happy to live to his age.”
  • Patient may answer with a number of 3 or less when asked to rank how important the behaviour change is to them. This is an arbitrary number. 
  • Before asking the patient to do the behaviour, or before assessing confidence, consider conviction building activities. 

Medium: 4 - 6

  • Patient has textbook knowledge of why change is beneficial, but has no personal reason.E.g. “Smoking is bad because it affects heart health and the risk for cancer.”
  • Patient may answer with a number of 4 to 6 when asked to rank how important the behaviour change is to them. This is an arbitrary range.
  • Before asking the patient to do the behaviour, or before assessing confidence, you may wish to conviction building activities.

High: 7 - 10

  • Patient expresses a personal reason for making the change  (regardless of textbook knowledge). E.g. “I want to quit because my grand-daughter said she doesn’t like the smell when she hugs me. She cringes when I hug her."
  • May answer with a number between between 7 and 10 when asked to rank how important the behaviour change is to them. Again, this is an arbitrary range.
  • This patient is likely ready to make the behaviour change. Consider assessing for confidence first to find and solve barriers.  

Build Conviction

Consider these suggestions for increasing conviction: 

  1. Educate with permission. Provide benefits of the behavior change (with permission, so the patient isn't alienated.) The patient may or may not know them. E.g.
    • "John, how would you feel about me reviewing some of the ways that starting insulin has helped people?"
  2. Relate to personal benefits. Discuss how the behavior change could help one problem or one thing of importance that the patient has verbalized (“a benefit carrot”). E.g.
    • "John, how would you feel about me reviewing how starting insulin might help with your complaint of being so tired?"
  3. Elicit change talk. Repeat back statements the patient has made that are positive about the behavior or leaving towards positive.E.g.
    • "What made you say 5 instead of 0, when you rated how important this change was to you?" (The person must focus on the positives to answer this.)
    • "You said that taking insulin might help you. Tell me more about what you meant."
  4. Strengthen relationship. Try more rapport building strategies. People will consider more changes if they like you. However, this is not as strong as patients having their own personal reasons/benefits.E.g.
    • When appropriate: nod, mirror their body stance, lean forward when they talk, make eye contact, empathize, reflect back or paraphrase their statements, learn more about their resistance to change by asking more open-ended questions
  5. Ask if patient will consider a “thinking about” goal. This can help the patient indentify a personal benefit of high enough value to consider the behaviour change. E.g. 
    • "John, you said you didn’t want to take insulin right now. I respect that. I want to be sure you’ve considered all your reasons for not starting or for starting insulin. Big decisions, just like big purchases such as a house, require we make lists of the good and the bad. How would you feel about making a list of the good and the bad things that insulin could bring to you and your family’s life today, next year and a few years from now?"


Assess for Confidence

Remember, a patient's smiles don't necessarily mean high confidence. Also, don't assume a patient would tell you they aren't confident, even if you've had a trusting relationship with them for years. Clarify using questions like these when assessing confidence. 

  • "How confident do you feel about ____ (insert behaviour)?"
  • "On a scale of 1 – 10, how CONFIDENT are you that you could _____(insert behaviour)?"

Remember that high confidence does not mean the person has high conviction to change - they may feel confident they could change IF they wanted to. Assessing coinviction first, before assessing confidence, is often the best strategy.

Build Confidence (if adequate conviction)

If a person has high conviction, but their confidence is low (eg.<  7/10) consider confidence building strategies.

  1. Help patient identify barriers and solutions. E.g.
    • "What would get in the way of you_____ (insert behaviour)?" or "What is the hardest part about ____ (insert behavior)?"
    • "How do you think you could work around that barrier?"
    • "What needs to change to make it possible for you to  ___(insert behaviour)?"
  2. Focus on prior success. E.g.
    • "What helped you _____(insert the specfic behavior) in the past?"
    • "What worked in the past to help you succeed with a difficult change?"
  3. Add social supports. E.g.
    • "How would you feel about asking a friend or family member to support you while you make this change?"
  4. Make a SMART goal based on stage of change. E.g.
    • A "Preparing" Goal:  "How do you feel about setting a goal to 'prepare to' exercise? You mentioned you have a treadmill in the garage, but don't know where in the day to use it and where in the house to put it.  A goal could be to analyze your options before our next visit and before you start exercising. What do you think?"  (Interestingly, some patients will stick just to this goal; others will do it and then jump to exercising as their readiness to change has increased.)
    • A "Doing" Goal: "How would you feel about setting a goal for doing some exercise?"  Depending on the answer, you could set a SMART goal for action.
    • When uncertain what goal to suggest as patient may have increased or dropped a stage of change you could ask, "We've been talking about exercise. Between now and when we meet again, I'm not sure if you want to think about the pros/cons of it some more, or do some planning to figure out when and what you'd do for exercise or actally start exercising. What do you think you are ready for?" (Remember to wait for their answer, sometimes a long time as they process this quesion and how they feel about it.)

The Order Matters!

  • Assess First (find the target) - is it conviction or confidence that needs increasing first? 
  • Coach Second (aim at the target)

 dcc conviction blind target 2018

 When we forget to assess conviction first and assume people are on board with change, maybe because of their smiles and humour, we put the therapeutic relationship at risk. We risk:

  • disrespecting patients' autonomy and time
  • losing patients' trust
  • losing rapport and honest answers; alienating patients
  • decreasing our ability to help patients

Other Client Centred Skills

  • Acceptance and respect: Accept the patient and their choices without judgment. The patient is able to discuss feelings/actions without worrying about rejection or being admonished. We repect the patient's right to make decisions for themselves. We would like to provide more context and information to help them with their decisions, if they are agreeable. 
  • Empathy by using: 
    • Active listening - reflect feelings for clarity; repeat key words/phrases or paraphrase; summarize. If a patients repeats elements of a story, it is usually because they feel they are not being listened to. 
    • Body Language: Facing patient and eyes on them; leaning forward
    • Open-ended questions
  • Tone of voice: Not hiding behind a professional facade
  • Pointing out incongruence: E.g. "On one hand, you feel/know___, and on the other you are doing ___." Give patient time to think about it and respond.

Case 1: Marta

The diabetes educator asks, “Marta, how do you feel doing some gluocose checks?”

Marta shrugs, then she sighs heavily with annoyance and says, “I think it will get in the way of my work. I know you need the numbers for the insulin doses but I have to take care of kids for a living. I run a daycare. It’s chaotic. Those kids keep me so busy! And, those kids are much more important than me!”

1. Do you think Marta is ready to set a SMART goal to test once or twice daily? 

2. If you answered 'no', what do you think she needs first?

A.  An increase in conviction. See suggestions and choose one you think is best suited to her.
B.  Or an increase in confidence. See suggestions and choose one you think is best suited to her.

If you aren't sure if glucose checking is important to her, or you want to clarify in a more definitive way, what question could you ask her? See suggestions for assessing conviction.

Case 2: Kareem

The diabetes educator asks: “Kareem, how do you feel about doing some glucose monitoring?”

Kareem answers: “I used to do it regularly. I had a whole system. I think it helped fine-tune my meds back then. Also it kept my wife off my back if I tested, haha! She’s always worried about me so I tried to test to keep her happy. I really feel bad when she worries. Ya. I could definitely do better - my wife wouldn’t be so concerned then and I wouldn’t feel guilty for making her worry. I’m sure I would learn a lot and feel better too.”

  1.  Do you think Kareem has low, moderate or high conviction to monitor glucose?
  2. Do you want to work on building conviction or confidence with him? 
  3. Pick one:
    • The one best conviction building strategy for Kareem (only if he needs it)
      OR the one best confidence building strategy for Kareem (only if you believe he's convinced gluocose testing is of value in his life)
Of course many strategies can work, we're only wondering which you might try first given what he had to say above.