• Save
The  Magic Of  Behavior  Change Handout
Upcoming SlideShare
Loading in...5
×

Like this? Share it with your network

Share

The Magic Of Behavior Change Handout

  • 5,200 views
Uploaded on

 

  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Be the first to comment
No Downloads

Views

Total Views
5,200
On Slideshare
5,187
From Embeds
13
Number of Embeds
2

Actions

Shares
Downloads
0
Comments
0
Likes
3

Embeds 13

http://www.slideshare.net 12
http://www.apurva.com 1

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
    No notes for slide

Transcript

  • 1. The Magic of Behavior Change
  • 2. Objectives 1. Explain how psychosocial models can assist them in encouraging patient behavior changes. 2. Define motivational interviewing. 3. 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; 2003:10,11. Miller WR, et al. Motivational Interviewing. 2nd ed. Guilford Press; 2002:25.
  • 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 patient’s 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; 2003:139.
  • 6. Biomedical Behavioral Practitioner centered Patient centered Information giving Information exchange “Save” the patient Patient “saves” self Dictate behavior Negotiate behavior Compliance Adherence Authoritarian (P-C) Servant Motivate the patient Assess motivation Persuade, manipulate Understand, accept Resistance is bad Resistance is information Argue Confront Respect expected Respect earned
  • 7. Behavioral Model: Information-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 Skills Behavior Change Motivation Source: Fisher JD, Fisher WA. Psychol Bull, 1992, 111:455–474; Fisher JD et al. Health Psychol, 1996, 15:114–123; Carey MP et al. J Consult Clin Psychol, 1997, 65:531–541; Mazzuca SA. J Chronic Dis, 1982, 35:521–529. 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; 2002:217-250. Peterson KA, et al. Readiness to change and clinical success in a diabetes education program. J Am Board Fam Pract. 2002;15:266-271.
  • 9. Stages of Change (Transtheoretical) Model • 5 stages of change • Useful for selecting Precontemplation appropriate interventions • By identifying a patient's position in the change Maintenance Contemplation process, physicians can tailor the intervention, usually with skills they already possess. Action Preparation • The focus is not to convince the patient to change behavior but to help the patient move along the stages of change. Source: Prochaska, Am Psychol 1992; 47:1102-4.
  • 10. The Spirit of Health Behavior Change • Collaborate with the patient • Evoke their readiness to take action • Develop patient’s autonomy to take responsibility for their own health Miller WR, et al. Motivational Interviewing. 2nd ed. Guilford Press; 2002:33-34.
  • 11. Assessment } • Factors to consider – Age – Cultural issues – Language – Co-morbidities • Patient knowledge – Health literacy Identify and – Disease specific • Medications prioritize the • Complications patient’s – Management of disease process/lifestyle change barriers • Patient’s motivation – Change lifestyle – Manage disease – Support system
  • 12. Numerous Barriers • Depression/fear • Cost of care • Fatalism/denial • Age/physical limitations • Nonchalance • Cultural beliefs/traditions • Perfectionism • Lack of social support • Anxiety/ • Lack of understanding: Myths frustration
  • 13. Ambivalence • Person’s 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; 2002:13-19.
  • 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 patient’s internal conflict between their current behavior and their desired behavior Rollnick S, et al. Health Behavior Change: A Guide For Practitioners. Churchill Livingstone; 2003:23-24.
  • 15. Four Categories of Resistance 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; 2002:48
  • 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; 2003:109. Berger B. Motivational interviewing helps patients confront change. Available at: http://www.uspharmacist.com/oldformat.asp?url=newlook/files/Phar/nov99relationships.cfm&pub_id=8&article_id=450. Accessed January 13, 2004.
  • 18. The Menu of Strategies: Elicit • Opening strategy: discussing patient’s lifestyle, how does the patient view it? • A typical day: what’s the routine? – Needed for tailoring – Identifying dietary needs/problems – Exercise Rollnick S, et al. Health Behavior Change: A Guide For Practitioners. Churchill Livingstone; 2003:112-113. Berger B. Motivational interviewing helps patients confront change. Available at: http://www.uspharmacist.com/oldformat.asp?url=newlook/files/Phar/nov99relationships.cfm&pub_id=8&article_id=450. 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? url=newlook/files/Phar/nov99relationships.cfm&pub_id=8&article_id=450. Accessed January 13, 2004.
  • 20. Numerous Barriers • Depression/fear • Cost of care • Fatalism/denial • Age/physical limitations • Nonchalance • Cultural beliefs/traditions • Perfectionism • Lack of social support • Anxiety/ • Lack of understanding: Myths frustration
  • 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. 2000:61:1409-1416.
  • 23. Readiness Ruler
  • 24. 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. 2000:61:1409-1416.
  • 25. Readiness Ruler: Follow-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? – Don’t kick yourself—long 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?
  • 26. 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
  • 27. 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; 2003:111-112. Berger B. Motivational interviewing helps patients confront change. Available at: http://www.uspharmacist.com/oldformat.asp? url=newlook/files/Phar/nov99relationships.cfm&pub_id=8&article_id=450. Accessed January 13, 2004.
  • 28. The Menu of Strategies: Elicit • The future and the present— additional 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; 2003:112. Berger B. Motivational interviewing helps patients confront change. Available at: http://www.uspharmacist.com/oldformat.asp? url=newlook/files/Phar/nov99relationships.cfm&pub_id=8&article_id=450. Accessed January 13, 2004.
  • 29. The Five General Principles of Health Behavior Change • READS • Roll with resistance • Express empathy • Avoid arguing • Develop discrepancy • Support self-efficacy Miller WR, et al. Motivational Interviewing. 2nd ed. Guilford Press; 2002:36. Berger B. Motivational interviewing helps patients confront change. Available at: http://www.uspharmacist.com/oldformat.asp?url=newlook/files/Phar/nov99relationships.cfm&pub_id=8&article_id=450. Accessed January 13, 2004.
  • 30. Principles of Health Behavior Change: Roll With Resistance • Use understanding, empathy • Get clarification • New perspectives are invited, not imposed • Don’t 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; 2002:36. Berger B. Motivational interviewing helps patients confront change. Available at: http://www.uspharmacist.com/oldformat.asp? url=newlook/files/Phar/nov99relationships.cfm&pub_id=8&article_id=450. Accessed January 13, 2004.
  • 31. Principles of Health Behavior Change: Express Empathy • An objective identification of another person’s 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; 2002:36. Berger B. Motivational interviewing helps patients confront change. Available at: http://www.uspharmacist.com/oldformat.asp?url=newlook/files/Phar/nov99relationships.cfm&pub_id=8&article_id=450. 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
  • 33. Principles of Health Behavior Change: Avoid Arguing • Don’t add to the person’s resistance • Arguing forces people to defend the behavior you are trying to change • Empathy sets you up as being on “their” side • Confront, but don’t argue • Feelings aren’t arguable Berger B. Motivational interviewing helps patients confront change. Available at: http://www.uspharmacist.com/oldformat.asp?url=newlook/files/Phar/nov99relationships.cfm&pub_id=8&article_id=450. 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; 2002:36. Berger B. Motivational interviewing helps patients confront change. Available at: http://www.uspharmacist.com/oldformat.asp?url=newlook/files/Phar/nov99relationships.cfm&pub_id=8&article_id=450. Accessed January 13, 2004.
  • 35. Principles of Health Behavior Change: Support Self-Efficacy • A person’s belief in the possibility of change is an important motivator • Notice the positive, including statements, not just behaviors • Let the person know you’ve 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; 2002:36. Berger B. Motivational interviewing helps patients confront change. Available at: http://www.uspharmacist.com/oldformat.asp? url=newlook/files/Phar/nov99relationships.cfm&pub_id=8&article_id=450. 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 patient’s Goals and Values