Facilitating Change

1
Facilitating Change

• Motivational Interviewing

2
Setting Goals for Change

• Ideally, the goal must be the patients goal,
  unless the goals are in the Best Interest of
  the patient.
• Break the goal down into manageable chunks.
• If the person feels they have failed to achieve a
  goal, review it, modify the goal (simplify it,
  put supportive strategies in place) and try again.

3
Facilitating Behaviour Change Motivational
Interviewing

• Cycle of Change
• (Prochaske DiClemente, 1982)
• Individuals have very basic motivations, and more
  complex ones.
• Motivation is not a personality trait or a
  static, stable entity (as in she is a very
  motivated person) but rather acknowledges that
  we all have motivation

4
Stages of Change

• Pre Contemplation - The person is not feeling
  ready to change, or even really thinking about
  it.
• Contemplation - The person may start to become
  more and more aware of the potential benefits of
  making a change.
• Preparation - At this point, the person has
  decided that they definitely do want to make a
  change, and start to make plans for how they can
  overcome barriers to change.
• Action - The person is making active attempts to
  change.
• Maintenance - The person may gain confidence as
  they see themselves making progress and become
  assured that they will be able to change.
• Relapse - The person loses all intention to
  carry on with the changes they are trying to
  make.

5
Motivational Interviewing

• Once the importance of change has been explored,
  and if it is felt that changing is important,
  then confidence can be brought into the equation.
• There needs to be a high level of both importance
  and confidence for change to occur.

Behaviour Change

• On a scale of 1-10, how important is it for you
  to change right now?
• 1 2 3 4 5
  6 7 8 9
  10
• On a scale of 1-10, how confident do you feel
  that you could change?
• 1 2 3 4 5
  6 7 8 9
  10

6
Resistance to Change

• If you feel that a person is being resistant to
  change, you need to change your tack.
• How resistance is communicated
• Body language e.g. avoiding eye contact, folded
  arms.
• Presenting reasons for not changing (e.g. Yes,
  but)
• Making excuses for not changing.
• Disputing or directly challenging you, your
  information, and your competence.
• Arguing, interrupting, ignoring or denying

7
Overcoming Roadblocks and Resistance
Stage Technique/Strategy
Pre-Contemplation Roll with Resistance Develop Discrepancy
Contemplation Affirming Provide personally relevant information Scaling questions Pros and cons list Roll with resistance Explore barriers Decisional balance sheet
Determination/ Preparation Affirming Action plan motivation list, problem solving, final barriers
Action Praise, support, reinforcement Amendments to action plan
Maintenance Reinforcement and rewards Pre-empt slips /relapse prevention Praise emphasis on gains
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Overcoming Roadblocks and Resistance

• Roll with Resistance - Avoid confrontation and
  try to get the person you are working with to
  recognise that they need/want to change
  themselves (rather than being told).
• Rolling with Resistance Approaches
• Avoid Arguing - avoid having a direct, head-on
  argument with an individual as this is likely to
  make them feel defensive.
• Listen - By showing that you have heard what they
  are saying, you may prevent them from
  instinctually being defensive
• Encourage - encourage the individual to come up
  with their own suggestions for ways of changing
  their behaviour
• Reflect - By doing it in a non-judgmental way,
  they will be assured that you are simply trying
  to understand them, rather than contradict them
  or express your own views.
• Alternative viewpoints - By doing this, you are
  getting them to look at the other side of the
  argument but without directly challenging their
  views or passing judgment on their choices.

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Overcoming Roadblocks and Resistance

• Develop Discrepancy - The aim of this strategy is
  to show a person that there is a discrepancy
  between their current behaviour and their desired
  or ideal behaviour.
• Affirmation - Affirmations are statements that
  acknowledge and recognise the positive steps that
  a patient has made in the direction of change.
• Provide Personally Relevant Information - The
  things that make people really want to change are
  the things that are personally relevant to them.

10
Overcoming Roadblocks and Resistance

• Scaling Questions - Scaling questions can be
  really helpful as they often allow you to break
  up the whole process of change into smaller
  chunks, making it less daunting for patients.
• Pros and Cons List - It can be hard to see the
  big picture but when its all written down in
  front of you, you can really begin to see how
  many benefits there could be to changing.
• Explore Barriers - It is also important that you
  explore the barriers that are preventing change
  or making change more difficult., and validate
  these so that the person knows that you are
  acknowledging how difficult it is for them to be
  changing their behaviour.

11
Activity

• One way of exploring pros and cons, is to use a
  decisional balance worksheet with patients.
• This allows you to not only look at the pros and
  cons of changing, but also the pros and cons of
  not changing (in reality, there are positives to
  carrying out behaviours which are bad for us
  otherwise we wouldnt do them! It is important to
  acknowledge this as well as looking at the
  negatives of a given behaviour).
• Draw out your own decisional balance sheet, and
  either use a change which you would like to make,
  or make up an example (e.g. stop smoking, eat
  healthier diet, cut down alcohol).

Pros Cons


Change No Change
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Overcoming Roadblocks and Resistance

• Action Plan - An action plan is a formal, written
  up plan of steps to take towards change. After
  setting a goal, ask the patient, how confident do
  you feel that you can achieve this goal on a
  scale of one to ten. If they give a number of 6
  or lower, you might want to explore the reasoning
  behind this, and if needs be, change the goal
  until it becomes something which they actually
  feel confident that they can achieve.
• Praise Support and Reinforcement - It is
  important that all steps towards changing are
  acknowledged and praised, no matter how small
  they are. There is never a black and white divide
  of succeed and fail, think of these two points as
  being either side on a gradual scale

Fail Made some progress Made
moderate progress Made good progress
Succeed
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Overcoming Roadblocks and Resistance

• Amendments - Changing a goal to make it more
  achievable is not a failure it may just be that
  the original goal was not realistic enough or not
  attainable at the current point in time. It is
  much better in the long run to amend goals and
  action plans than it is to stay focused on an
  unachievable goal.
• Rewards - When people are trying to change, it
  can be nice to know that at the end of each step
  there is a reward waiting for us. It doesnt have
  to be something big or expensive, just something
  which feels rewarding for that particular
  individual.
• Pre-empt Slips/Relapse Prevention - The key to
  making successful changes is to be aware of
  situations which might lead to us slipping up, be
  prepared for the possibility that we might slip
  up, and plan for what we will do afterwards.

14
Summary

• There are many reasons why an individual would
  want to change, or would not want to change.
• Our behaviour and motivations are all extremely
  personal, so telling someone what they should do
  and why they should do it, very rarely works.
• Assess and facilitate motivation for change
  through motivational interviewing. Find out your
  patients motivation and let them do the
  reasoning (with a little guidance from
  yourself).
• Use the tactics outlined to overcome roadblocks
  to change and remember that most people will have
  slip ups/relapses it is all part of changing.