The Magic of Behavior Change

1
The Magic of Behavior Change
2
Objectives

• Explain how psychosocial models can assist them
  in encouraging patient behavior changes.
• Define motivational interviewing.
• Discuss techniques of motivational interviewing

3
Health Behavior Change

• A strategy and collection of methods geared to
  the brief patient-centered consultation, based
  on
• Motivational Interviewing
• Stages of change model
• It is
• Patient-centered
• Directive
• A method of communication
• Used to explore and resolve ambivalence.

Rollnick S, et al. Health Behavior Change A
Guide For Practitioners. Churchill Livingstone
200310,11. Miller WR, et al. Motivational
Interviewing. 2nd ed. Guilford Press 200225.
4
Vision of this Learning Experience

• Evolution from the biomedical way of thinking
• Traditional model
• Tell patients what to do
• Because I said so
• Yes, but you will end up with this problem____.
• To the psychosocial model
• Empowerment where the HCP and patient are a team
• Promotion of patient involvement in their care
• Determining patients barriers and goal setting
• A paradigm shift for the provider of care      

5
Biomedical Model of Health and Illness

• Assumes the patient is or should be sufficiently
  motivated by illness to obey instructions
• Treatments are offered to patients who are not
  ready to follow them
• Reflects bias toward treating the disease and
  fails to address the behavioral requirements of
  the treatment
• Interventions following this model are unlikely
  to cause sustained changes in compliance

WHO. Adherence to Long-Term Therapies Evidence
for Action. WHO 2003139.
6
Biomedical Behavioral
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Behavioral ModelInformation-Motivation-Behavior
Skills Model

• Presence of both information and motivation
  increase the likelihood of adherence
• Interventions based on this model have been
  effective in influencing behavioral change in a
  variety of clinical applications

Information
Behavior Change
Behavior Skills
Motivation
Source Fisher JD, Fisher WA. Psychol Bull, 1992,
111455474 Fisher JD et al. Health Psychol,
1996, 15114123 Carey MP et al. J Consult Clin
Psychol, 1997, 65531541 Mazzuca SA. J Chronic
Dis, 1982, 35521529. as quoted in WHO, 2003.
8
Evidence of Effectiveness

• Motivational Interviewing techniques have been
  effective for treating alcohol and drug problems,
  patients with diabetes, hypertension, and bulimia
• The Motivational Interviewing process has been
  found superior to no-treatment control groups
• Readiness to change model was able to predict
  clinical improvement in patients with diabetes

Miller WR, et al. Motivational Interviewing. 2nd
ed. Guilford Press 2002217-250. Peterson KA, et
al. Readiness to change and clinical success in a
diabetes education program. J Am Board Fam Pract.
200215266-271.
9
Stages of Change (Transtheoretical) Model

• 5 stages of change
• Useful for selecting appropriate interventions
• By identifying a patient's position in the change
  process, physicians can tailor the intervention,
  usually with skills they already possess.
• The focus is not to convince the patient to
  change behavior but to help the patient move
  along the stages of change.

Precontemplation
Contemplation
Maintenance
Preparation
Action
Source Prochaska, Am Psychol 1992 471102-4.
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The Spirit of Health Behavior Change

• Collaborate with the patient
• Evoke their readiness to take action
• Develop patients autonomy to take responsibility
  for their own health

Miller WR, et al. Motivational Interviewing. 2nd
ed. Guilford Press 200233-34.
11
Assessment

• Factors to consider
• Age
• Cultural issues
• Language
• Co-morbidities
• Patient knowledge
• Health literacy
• Disease specific
• Medications
• Complications
• Management of disease process/lifestyle change
• Patients motivation
• Change lifestyle
• Manage disease
• Support system

• Identify and prioritize the patients barriers

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Numerous Barriers

• Depression/fear
• Fatalism/denial
• Nonchalance
• Perfectionism
• Anxiety/
• frustration

• Cost of care
• Age/physical limitations
• Cultural beliefs/traditions
• Lack of social support
• Lack of understanding Myths

13
Ambivalence

• Persons desire to do nothing
• Can be a key issue that must be resolved for
  change to occur
• Health Behavior Change process may help people
  get unstuck from their ambivalence

Miller WR, et al. Motivational Interviewing. 2nd
ed. Guilford Press 200213-19.
14
Resistance Can Be Bad or Good

• Resistance can disrupt and impact the rapport
  between the patient and healthcare provider
• Resistance can be a sign of a patients internal
  conflict between their current behavior and their
  desired behavior

Rollnick S, et al. Health Behavior Change A
Guide For Practitioners. Churchill Livingstone
200323-24.
15
Four Categories ofResistance Behavior

• Negating
• blaming, disagreeing, excusing, minimizing,
  claiming impunity, pessimism, reluctance,
  unwillingness to change
• Arguing
• challenging, discounting, hostility
• Interrupting
• Ignoring
• Inactivity patient does not fill prescription

Miller WR, et al. Motivational Interviewing. 2nd
ed. Guilford Press 200248
16
YES, BUT and PERSUASIVE COMMUNICATION

• Are NOT the solution to resistance!
• Understanding, exploration, and patience are the
  solution!

17
Health Behavior Change Techniques

• Elicit-Provide-Elicit
• Menu of Strategies
• The Five Principles
• READS
• Helpful Tools
• Readiness Rulers
• The Envelope

Rollnick S, et al. Health Behavior Change A
Guide For Practitioners. Churchill Livingstone
2003109. Berger B. Motivational interviewing
helps patients confront change. Available at
http//www.uspharmacist.com/oldformat.asp?urlnewl
ook/files/Phar/nov99relationships.cfmpub_id8art
icle_id450. Accessed January 13, 2004.
18
The Menu of Strategies Elicit

• Opening strategy discussing patients lifestyle,
  how does the patient view it?
• A typical day whats the routine?
• Needed for tailoring
• Identifying dietary needs/problems
• Exercise

Rollnick S, et al. Health Behavior Change A
Guide For Practitioners. Churchill Livingstone
2003112-113. Berger B. Motivational interviewing
helps patients confront change. Available at
http//www.uspharmacist.com/oldformat.asp?urlnewl
ook/files/Phar/nov99relationships.cfmpub_id8art
icle_id450. Accessed January 13, 2004.
19
The Menu of Strategies Elicit

• The good things and bad things
• What do they like and dislike about the proposed
  changes?
• What is their representation of the illness and
  its treatment?
• Do they agree with the MD?
• Do they believe they can do what is asked? What
  will help?
• What are the barriers?

Berger B. Motivational interviewing helps
patients confront change. Available at
http//www.uspharmacist.com/oldformat.asp?urlnewl
ook/files/Phar/nov99relationships.cfmpub_id8art
icle_id450. Accessed January 13, 2004.
20
Numerous Barriers

• Depression/fear
• Fatalism/denial
• Nonchalance
• Perfectionism
• Anxiety/
• frustration

• Cost of care
• Age/physical limitations
• Cultural beliefs/traditions
• Lack of social support
• Lack of understanding Myths

21
Prioritizing Barriers

• Evaluate and Identify barriers, then.
• Prioritize
• Patient prioritizes barriers
• To assist, HCP may ask.
• What is the one thing that most keeps you from
• Can you pick out a single problem that most
  hinders your progress in
• If I told you that you can live a long, healthy
  and enjoyable life, and you were going to
  disagree with me, what would you say?
• Patient and HCP agree on a plan

22
Readiness Ruler

• Useful tool when you encounter resistance
• Elicits change talk
• Evaluates two concepts
• Importance
• Confidence
• Scale from 1 to 10

Zimmerman GL, et al. A stages of change
approach to helping patients change behavior. Am
Fam Physician. 2000611409-1416.
23
Readiness Ruler
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Readiness Ruler Questions

• How important is this change for you?
• How confident are you that you can make this
  change if you want to?
• Why did you choose a ____, not a 1?
• What would have to happen for it to be a _____?
  (next highest number from what they stated)

Zimmerman GL, et al. A stages of change
approach to helping patients change behavior. Am
Fam Physician. 2000611409-1416.
25
Readiness RulerFollow-up to Patient Response

• If the answer is 4 to 10, ask or say.
• Congratulations! What is helping you?
• What else can help?
• What are your high-risk situations?
• If the answer is 1-5, ask or say.
• Would you consider yourself to have fallen off
  the wagon? If so, what worked for a while?
• Dont kick yourselflong term change almost
  always takes a few cycles.
• What did you learn from the experience that will
  help you when you give it another try?

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The Envelope

• Elicits change talk
• If I handed you an envelope, what would the
  message inside have to say to get you to
  ________?
• Useful when there is ambivalence

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The Menu of Strategies Provide

• Providing information is the patient ready for
  information?
• Provide patient with all appropriate information
• Dosing how much to take and when to take it
• What the expected onset of action is
• Most common side effects and what to do if any
  occur
• What to do if there are problems
• Ask if patient has any further questions

Rollnick S, et al. Health Behavior Change A
Guide For Practitioners. Churchill Livingstone
2003111-112. Berger B. Motivational interviewing
helps patients confront change. Available at
http//www.uspharmacist.com/oldformat.asp?urlnewl
ook/files/Phar/nov99relationships.cfmpub_id8art
icle_id450. Accessed January 13, 2004.
28
The Menu of Strategies Elicit

• The future and the presentadditional concerns
• Helping with decision making
• What are your thoughts now about managing
  your...
• Where does this leave you now?
• Do you anticipate having any help?
• ELICIT PROVIDE ELICIT

Rollnick S, et al. Health Behavior Change A
Guide For Practitioners. Churchill Livingstone
2003112. Berger B. Motivational interviewing
helps patients confront change. Available at
http//www.uspharmacist.com/oldformat.asp?urlnewl
ook/files/Phar/nov99relationships.cfmpub_id8art
icle_id450. Accessed January 13, 2004.
29
The Five General Principles of Health Behavior
Change

• R E A D S
• Roll with resistance
• Express empathy
• Avoid arguing
• Develop discrepancy
• Support self-efficacy

Miller WR, et al. Motivational Interviewing. 2nd
ed. Guilford Press 200236. Berger B.
Motivational interviewing helps patients confront
change. Available at http//www.uspharmacist.com/
oldformat.asp?urlnewlook/files/Phar/nov99relation
ships.cfmpub_id8article_id450. Accessed
January 13, 2004.
30
Principles of Health Behavior Change Roll With
Resistance

• Use understanding, empathy
• Get clarification
• New perspectives are invited, not imposed
• Dont give person a reason to resist more
• Resistance is a signal to respond differently
• Repeat your understanding
• The person is a primary resource in finding
  answers and solutions

Miller WR, et al. Motivational Interviewing. 2nd
ed. Guilford Press 200236. Berger B.
Motivational interviewing helps patients confront
change. Available at http//www.uspharmacist.com/
oldformat.asp?urlnewlook/files/Phar/nov99relation
ships.cfmpub_id8article_id450. Accessed
January 13, 2004.
31
Principles of Health Behavior Change Express
Empathy

• An objective identification of another persons
  emotions (not their experience)
• Done throughout the process (menu)
• Identify and understand resistance, reasons for
  unhealthy behaviors without judgment
• Creates a climate for change through trust

Miller WR, et al. Motivational Interviewing. 2nd
ed. Guilford Press 200236. Berger B.
Motivational interviewing helps patients confront
change. Available at http//www.uspharmacist.com/
oldformat.asp?urlnewlook/files/Phar/nov99relation
ships.cfmpub_id8article_id450. Accessed
January 13, 2004.
32
What is NOT Listening

• Ordering, directing, commanding
• Warning or threatening
• Giving advice, suggestions, solutions
• Persuading or lecturing
• Moralizing, preaching (fixing, healing, and
  converting)
• Disagreeing, judging, criticizing, or blaming
• Agreeing, approving, or praising
• Shaming, ridiculing, or labeling
• Reassuring, sympathizing, or consoling
• Questioning or probing

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Principles of Health Behavior Change Avoid
Arguing

• Dont add to the persons resistance
• Arguing forces people to defend the behavior you
  are trying to change
• Empathy sets you up as being on their side
• Confront, but dont argue
• Feelings arent arguable

Berger B. Motivational interviewing helps
patients confront change. Available at
http//www.uspharmacist.com/oldformat.asp?urlnewl
ook/files/Phar/nov99relationships.cfmpub_id8art
icle_id450. Accessed January 13, 2004.
34
Principles of Health Behavior Change Develop
Discrepancy

• Discrepancy Dissonance
• Good things and bad things about change
• Pros and cons
• Throw system out of kilter
• Restate the discrepancies heard
• Change is motivated by a perceived discrepancy
  between present behavior and important personal
  goals or values

Miller WR, et al. Motivational Interviewing. 2nd
ed. Guilford Press 200236. Berger B.
Motivational interviewing helps patients confront
change. Available at http//www.uspharmacist.com/
oldformat.asp?urlnewlook/files/Phar/nov99relation
ships.cfmpub_id8article_id450. Accessed
January 13, 2004.
35
Principles of Health Behavior Change Support
Self-Efficacy

• A persons belief in the possibility of change is
  an important motivator
• Notice the positive, including statements, not
  just behaviors
• Let the person know youve noticed
• The person, not the counselor, is responsible for
  choosing and carrying out change
• Let them know how you feel
• Praise the behavior, not the person
• Continue to support self-efficacy throughout the
  process

Miller WR, et al. Motivational Interviewing. 2nd
ed. Guilford Press 200236. Berger B.
Motivational interviewing helps patients confront
change. Available at http//www.uspharmacist.com/
oldformat.asp?urlnewlook/files/Phar/nov99relation
ships.cfmpub_id8article_id450. Accessed
January 13, 2004.
36
Health Behavior Change Summary

• Elicit - Provide - Elicit
• Address ambivalence, create dissonance
• Explore resistance
• Ask evocative questions
• Exploring the concerns and the pros and cons of
  change
• Ask the patient to elaborate
• Elicit change talk
• Identify patients Goals and Values