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Practical strategies to institute behaviour change in your patients Ilda Caeiro, B.A./B.S.W., M.S.W., R.S.W. Slide 2 Objectives Self-Determination Theory-a paradigm for health care Self-Determination Theory-a paradigm for health care Motivational Interviewing and Supporting Research Motivational Interviewing and Supporting Research Defining Motivational Interviewing Defining Motivational Interviewing Using motivational interviewing to address resistance and readiness for chance Using motivational interviewing to address resistance and readiness for chance Slide 3 Before we begin A fun little exercise Slide 4 So why is it so hard to change? Is it social, environmental, or internal influences? Michelangelos David after his stay in North America Slide 5 Self-Determination Theory-A paradigm for Healthcare General Theory of behaviour for human beings-respecting, supporting, and facilitating autonomy in our patients Slide 6 Solutions do not always seem rational Slide 7 Can we really motivate change? Case Study John is an 18year old young man with class three obesity Pre-contemplative phase He has come to the clinic with a weight loss goal of 100lbs John wants to do Optifast program He has been unsuccessful in managing his weight independently Hx of binge eating behaviours and consuming high levels of alcohol Hes a typical teenagerenjoys going out with friends, which typically consists of drinking and eating out What do you think is Johns motivation to lose weight at this time? Can he be motivated to make lifestyle changes? i.e. reduce drinking and partying with his friends and not eat out as often? Slide 8 Patients do not always see the risks Slide 9 Motivation??? Motivation can be defined as human energy directed toward a particular goal Its about free choice Assumptions: Humans are innately motivated toward well being and personal growth Slide 10 Three Psychological Needs Supporting Optimal Motivation AUTONOMY COMPETENCE RELATEDNESS ***motivational Interviewing supports autonomy and relatedness*** Slide 11 Motivational Interviewing (MI) Ideal for patients in pre-contemplation and contemplation stages of change Goal is to assist patients move from pre- contemplation and contemplation stages into preparation and action stages ***see handout from American Medical Association for Assessment of Patient Readiness and Stages of Change*** Slide 12 Effectiveness of Motivational Interviewing (MI) within Health Care Studies examining the use of MI or MI in combination with other interventions provide evidence for the effectiveness of MI within health care Studies examining the use of MI or MI in combination with other interventions provide evidence for the effectiveness of MI within health care Butler et al. 1999; 49: 611-612 Slide 13 MI has been effective in assisting patients: a) control glucose levels (Channon et al. 2003, 2007; Smith et al. 1997; Viner et all 2003; Smith et al. 2007) b) increase physical activity (Smith-West et al. 2007) c) decrease weight (Smith et al. 2007) d) engage in dietary changes (Brug et al. 2007, Clark & Hampson, 2001) Slide 14 Motivational Interviewing in Health Promotion Smith West et al. (2007) Population- overweight women Subjects-217 Dose of MI-5, 45minutes sessions, one delivered before starting behavioural obesity treatment and then again at 3, 6, 9, 12months. Attrition rate-7% F/U- 6 and 18months Outcome-women in motivational interviewing lost significantly more weight at 6 months and 18months. Significant greater A1C reductions were observed in those undergoing motivational interviewing at 6months, but not at 18months Slide 15 Bennet, Lyons, Winters-Stone, Nail and Scherer (2007) Population-Physically Inactive Adult Cancer Survivors Subjects- 56 Comparison Groups- Motivational Interviewing (28), Control (28) Dose of MI-one 30minute Session and two follow up telephone calls Attrition rate-14% F/u-3, 6months Outcome- a significant increase in physical activities was noted in the MI group compared to the control group Slide 16 Carels et al. (2007) Subjects-55 Population-Obese Sedentary Adults Comparison Groups-behavioural weight loss program(27), behavioural weight loss with stepped care (28)of which 19 received MI Dose of MI-46-60min sessions provided to participants in the behavioural weight loss program with stepped care who failed to meet their weight loss goals Attrition Rates-16% F/U- 3, 6,12, 18 weeks Outcome-Participants who received MI lost significantly more weight and engaged in more physical activity than those who did not Slide 17 Slide 18 Building MI into Clinical Practice Health care professionals are often concerned about the time it takes to integrate MI into clinical practice Health care professionals are often concerned about the time it takes to integrate MI into clinical practice One study of primary care physicians found that MI took an average of 9.69 minutes One study of primary care physicians found that MI took an average of 9.69 minutes Borelli et al. 2007 Slide 19 The effectiveness of MI as a patient-centered approach MI overlaps with patient-centered medicine in that both approaches involve patient acceptance, collaboration, open- ended questions, and listening skills. MI overlaps with patient-centered medicine in that both approaches involve patient acceptance, collaboration, open- ended questions, and listening skills. Slide 20 Motivational Interviewing: A Review MI is a communication method, not a theory or a technique, which supports autonomy and relatedness for patients MI is a communication method, not a theory or a technique, which supports autonomy and relatedness for patients Definition: Definition: Motivational interviewing is a directive, client-centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence Stephen Rollnick, Ph.D., & William R. Miller, Ph.D. (1995) Slide 21 The Interviewing process Motivational interviewing is based on three key components: Collaboration (vs. Confrontation) Collaboration (vs. Confrontation) Evocation (vs. Education) Evocation (vs. Education) Autonomy (vs. Authority) Autonomy (vs. Authority) Slide 22 The spirit of motivational interviewing 1. Motivation to change is elicited from the client, and not imposed from without 2. It is the client's task, not the counsellor's, to articulate and resolve his or her ambivalence 3. Direct persuasion is not an effective method for resolving ambivalence Slide 23 Direct Persuasion-Does it Work? Slide 24 4. The counselling style is generally a quiet and eliciting one 5. The counsellor is directive in helping the client to examine and resolve ambivalence 6. Readiness to change is not a client trait, but a fluctuating product of interpersonal interaction 7. The therapeutic relationship is more like a partnership or companionship than expert/recipient roles Slide 25 Back to John Typically change ONLY occurs when humans believe that the cost of NOT changing is HIGHER than maintaining the status quo So for John, change would only occur if the rewards of change were HIGHER than drinking and partying with his friends Slide 26 Update on John After engaging John in MI and identifying his true motivation for change, John engaged in significant lifestyle changes He stopped drinking Would hang out with friends but not eat out Journal food, mood and activity Engaged in regular exercise Addressed roots of emotional eating Results John lost 25lbs in four weeks and has continued to lose weight He reports higher self esteem and self confidence What was Johns Motivation??? Slide 27 Role of the Practitioner: Four Principles of MI Express empathy Develop discrepancy****** Roll with resistance avoid argumentation Support self-efficacy Slide 28 Where to begin A good place to start is by letting the patient set the agenda for the meeting. Slide 29 Five Strategies used throughout Motivational Interviewing: Open ended questions Affirm Reflective listening Summarizing Elicit Change Talk self motivational statements Slide 30 Methods for Evoking Change Talk Using the Importance Ruler 0 1 2 3 4 5 6 7 8 9 10 Not at allExtremelyImportant Slide 31 Readiness Ruler 1. How important is it to start using some of these strategies/tools? 2. How confident are you that you could apply them in your practice? 3. How ready are you to actually use them? Slide 32 Ruler Questions How important would you say it is for you to lose weight? On a scale from 0-10, where 0 is not at all important and 10 being the most important thing at this time, where would you say you are? and how confident would you say you are, that if you decided to lose weight, you could do it Slide 33 Why are you at an ____ and not zero? What would it take for you to go from ___ to (a higher #) Slide 34 Methods for evoking change talk continued 2) Exploring the decisional balance Maintaining Current WeightLosing Weight Advantages Disadvantages Slide 35 3) Elaborating 4) Querying Extremes 5) Looking Back 6) Looking Forward 7) Exploring Goals and Values Methods for evoking change talk continued Slide 36 Evocative Questions Evocative questions ask the client directly for change talk in what ways does this concern you How would things be better if you changed Evocative questions ask for commitment so given all this, what do you think you will do next? whats your next step Slide 37 Looking Back Looking Forward Can you remember a time when you were pain free and active or eating was not a problem and you felt good about yourself? What was that time like? Think about what kind of a future you want to see for yourself? Slide 38 Exploring Goals How does the behaviour fit with the patients values and goals? What things do you regard as most important? How does this fit? What sort of person do you want to be? What sorts of things would you like to accomplish in your life? Slide 39 Slide 40 How Change Fits Together Desire Desire Ability Commitment Ability Commitment Behavioural Change ReasonsTaking Steps ReasonsTaking Steps Need Need Slide 41 DARN Why do you want to lose weight [Desire]? Why do you want to lose weight [Desire]? How would you do it, if you decided to [Ability]? How would you do it, if you decided to [Ability]? What, for you, are the three best reasons for losing weight [Reasons]? What, for you, are the three best reasons for losing weight [Reasons]? How important is it for you to lose weight [Need]? How important is it for you to lose weight [Need]? Slide 42 Negotiating a Change Plan The development of this plan is a process of shared decision making and negotiation that involves: a) Setting goals b) Considering change options c) Arriving at a plan d) Eliciting commitment Slide 43 Change Questions 1) How would you like for things to be different? 2) What is it that you want to change? 3) Lets take things one step at a time. What do you think is the first step? 4) Here is a variety of possibilities that people have used successfully. Which of these do you prefer? Which do you think might work best for you? Slide 44 Change Plan Worksheet 1. The changes I want to make are 2. The most important reasons why I want to make these changes are 3. The steps I plan to take in changing are 4. The ways other people can help me are 5. I will know that my plan is working if 6. Some things that could interfere with my plan are Slide 45 Case Study 30year old female in class III obesity 30year old female in class III obesity Married, with one young child Married, with one young child Works part time outside of the home Works part time outside of the home Physician referral with concerns pertaining to readiness/motivation Physician referral with concerns pertaining to readiness/motivation Full psycho-social completed Full psycho-social completed Patient presenting with ambivalence re: weight loss Patient presenting with ambivalence re: weight loss Initiated MI Initiated MI Patient disclosed childhood trauma and the use of food to heal Patient disclosed childhood trauma and the use of food to heal Described food as an only friend and found it difficult to diet due to feelings of deprivation Described food as an only friend and found it difficult to diet due to feelings of deprivation Felt she did not have time to exercise, eat healthy etc. Felt she did not have time to exercise, eat healthy etc. Slide 46 Where she is today Prior to engaging in formal Opti-fast program patient lost a total of 30lbs. With just three MI sessions Prior to engaging in formal Opti-fast program patient lost a total of 30lbs. With just three MI sessions Since commencing LCD, patient has lost over 100lbs Since commencing LCD, patient has lost over 100lbs Patient reports feeling in control of life and decisions Patient reports feeling in control of life and decisions Experienced increase in internal motivation Experienced increase in internal motivation Reports increase in assertiveness skills, self esteem, and body image as well as improvements in her inter- personal relationships. Reports increase in assertiveness skills, self esteem, and body image as well as improvements in her inter- personal relationships. Slide 47 TAKE HOME MESSAGE Ask where the person wants to go and get to know him/her Ask where the person wants to go and get to know him/her Inform the person about options and see what makes sense to them Inform the person about options and see what makes sense to them Listen to and respect what the person wants to do and offer help accordingly Listen to and respect what the person wants to do and offer help accordingly Slide 48