How often do doctors say something like this to patients? “It’s really important for you to do this; if you don’t you might … have a stroke, go blind, lose a leg, die or (insert a scary outcome here).” There are no solid data to answer this question, though patients report that conversations containing such direct threats are common in clinical encounters. The more important question is, do scare tactics work?
Fear-based messages in clinical encounters
Health communication experts call these types of messages fear-based appeals. Fear appeals create an emotional reaction to some “threat” of disease, disability or death, which in turn, is thought to motivate behavior change. Doctors may use fear-based messages when counseling patients about chronic disease self-management or prevention, especially when faced with a patient we believe to be unmotivated or non-adherent. In such situations, using fear as a tool is appealing because it is easy, doesn’t take much time and we know intuitively that fear can be a powerful motivator. Yet despite decades of research on the subject, there is no consensus on whether or how fear can be used effectively to motivate long-term behavior change.
Research supporting the effectiveness of fear appeals is generally from public health campaigns, where frightening facts or images can quickly capture the audience’s attention. This makes sense when a message sender is competing for audience attention among many billboards, advertisements and other messages. But it rarely makes sense when a doctor is alone in an exam room with a patient. For many patients, the 15 minutes they have with their doctor will be the 15 most important minutes of their day.
More important, research suggests that appeals to fear can cause harm. For example, in a study of patients with type 2 diabetes, patients recognized when their doctors were using scare tactics to motivate compliance, but many said such threats resulted in increased feelings of anxiety, incompetence and negativity towards their physician.
Why threatening patients rarely works
The reason threatening patients with bad outcomes often fails to persuade patients to change behavior lies in the powerful 2-way interdependency of fear and self-efficacy in prompting action. A recent meta-analysis of studies on fear-based messaging found that threatening information only sparks behavior change when self-efficacy is high, and self-efficacy is only correlated with behavior change when the individual perceives himself to be susceptible to a threat. Moreover, in the absence of strong levels of self-efficacy, raising fear levels can lead to maladaptive responses such as shutting down, feeling overwhelmed or denial. For clinicians this means that although fear-based messages can quickly increase a patient’s sense of being threatened, which may be a necessary predicate for behavior change, this fear must be matched with success in raising the patient’s sense of self-efficacy or it could backfire. The problem is that increasing self-efficacy is a laborious process.
Several communication methods work to increase patient self-efficacy, but none are quick or easy to implement. For instance,randomized controlled trials of motivational interviewing (MI) in primary care suggest that MI can increase self-efficacy and help patients achieve goals related to weight loss, blood pressure and outcomes related to substance use; but effective MI requires multiple counseling sessions and multidisciplinary teamwork.
There is also a robust evidence base behind self-determination theory (SDT), which leverages 3 psychological mechanisms related to self-efficacy to help individuals achieve long-term behavior change: autonomy (feeling internally motivated and not coerced into the recommended action), competence (feeling competent to act and to problem-solve), and relatedness (feeling connected to others). Studies of SDT-based interventions have shown positive effects on various health behaviors, such as smoking cessation, weight loss maintenance and physical activity. But the effective clinical use of SDT, like using MI, requires both time and teamwork and is challenging to implement in the real world of health care practice.
Can fear-based messages be used effectively?
Knowing this, is there ever an appropriate approach to the use of fear appeals during the clinic encounter? Consider, as an example, patients at high risk of developing diabetes. Will telling patients they have prediabetes and using the threat of developing diabetes and its potential consequences (i.e. kidney failure, losing a limb) stoke unproductive fear? Or could it be beneficial because the fear of developing diabetes motivates patients to change their lifestyles?
Many patients with prediabetes have described feeling fear, anxiety and uncertainty when first diagnosed. Fear and anxiety are also heightened when patients have witnessed a family member suffer the downstream consequences of diabetes, and these feelings are further intensified by the fact that few patients are confident they can make healthy lifestyle changes to reduce the threat of diabetes and its consequences. So, being diagnosed with prediabetes dramatically increases the perceived threat of diabetes, indeed some patients perceive it as inevitable, but self-efficacy is also generally low.
What should the physician do? A statement like, “You have prediabetes; if you don’t lose weight, you are going to develop diabetes which could lead to other more serious problems, like heart attacks or kidney failure” is likely to grab the patient’s attention but fail to motivate weight loss – it might even backfire, leading to resignation, denial or hopelessness. Evidence-based diabetes preventionprograms that help patients increase self-efficacy and chances of weight loss exist, using techniques derived from MI and SDT; but these programs takes months to complete and are typically offered outside the doctor’s office, in community-based organizations such as the YMCA. A more effective approach might be to say, “Having prediabetes means you are at high risk for developing diabetes, but there are thing you can do to avoid or prevent it –like losing weight, eating healthier and being more physically active. If you are interested, I’m going to give you a referral to a program that can help you prevent diabetes.” Then provide the patient with a direct referral to a diabetes prevention program or other evidence-based lifestyle program.
Perhaps in an ideal world, the physician would deliver a comprehensive MI and SDT-based intervention herself – usually many weeks of intensive work with modest reimbursement at best–but for most of us this is not realistic. Still, physicians play critical roles by helping patients understand their risk, supporting the patient’s autonomy, and by staying connected to and supportive of the patient through the behavior change process.
In sum, evidence suggests that fear appeals have limited utility in the clinical encounter, and that any appeal to fear must be coupled with communication strategies that increase motivation, autonomy and competence in patients. Using fear as part of an effective motivation strategy for patient behavior change requires a long-term, team-based approach, often extending beyond the doctor’s office.
Namratha Kandula, MD, MPH and Matthew Wynia, MD, MPH are the Directors for Patient and Physician Engagement in the American Medical Association’s Improving Health Outcomes Initiative.