Mi ttm sig final4 21_11

Facilitating Behavior Change:The Transtheoretical Model of Behavior Change andMotivational Interviewing
Barbara Chase, MSN, ANP-C, CDE
Sandra O’Keefe, CWC

Learning Objectives-Part I
At the conclusion of this presentation, attendees will be able to:
Define the 5 stages of the Transtheoretical Model (TTM) for behavior change
Assess patients’ current stage of behavior change using TTM
Identify the 10 processes of how to progress through TTM stages
Define Motivational Interviewing (MI)
Describe skills, styles and strategies used in MI
Understand how to use MI tools to assess readiness to change

Continuing Education Statement
Massachusetts General Hospital (OH-239/10-01-11) is an approved provider of continuing nursing education by the Ohio Nurses Association (OBN-001-91), an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation.
Criteria for successful completion include attendance at the entire event and submission of a complete evaluation form.
Barbara Chase, MSN, NP, CDE has no conflicts of interest to disclose.
Sandra O’Keefe, CWC has no conflicts of interest to disclose.

Transtheoretical Model of Behavior Change
Stages of Behavior Change
Prochaska, J.O., & DiClemente, C.C. 1983

Philosophy of Empowerment
(The patient is always the expert on himself)
Patient defines problem
Patient identifies feelings
Patient develops long term goals
Patient identifies short-term plan
Patient implements & evaluates plan
5

How do our perceptions change?

Change Process May Not Be Linear!

Moving across stages of change
10 Processes:
5 Cognitive:
Get information
Being moved emotionally
Considering how the behavior affects others
Self-image
Social Norms
5 Behavioral:
Make a commitment
Use cues
Use substitution
Social Support
Rewards
Prochaska, J.O., & DiClemente, C.C. 1983

Javier Part One
Javier is a senior in high school diagnosed with type 1 diabetes.
He just transferred to a new school and is experiencing problems. He has a negative attitude about school and is receiving poor grades that are putting him at risk of failing his first semester. He says that he hates school and dislikes the other students. When asked about his diabetes, he says that it makes him feel like a freak, and that he hates having the disease and hates his life. His most recent HbA1C, which covered the first 3 months of school, was 11.8%.
https://aade.learnflex.net/CourseDepot/86/Module2/video_sr.html
Source: AADE

Motivational Interviewing
A directive, person-centered counseling style for increasing intrinsic motivation by helping clients explore and resolve ambivalence
(Miller & Rollnick, 2002)
10

MI is a collaborative approach to helping people change their behavior regarding their health
Patient centered skills, styles, strategies can be learned by many members of the care team
Promotes change from within not from without
11

Identifies, explores, resolves ambivalence
Reveals patient motivation
Enhances conviction
Stimulates readiness for change
Creates a partnership not expert/recipient roles
12

Guiding Principles:
Express Empathy
Develop Discrepancies
Roll with Resistance (Avoid Argument)
Support Self-Efficacy
13

Expressing Empathy
Actively listen
Create safe accepting environment
Encourage expression of personal
thoughts, feelings, and experiences
Identify ambivalence
14

Expressing Empathy
Provide support and relay facts
Avoid giving advice or direct teaching unless requested
Patient determines pace and direction of conversation
Patient makes the decision to embark on behavior change
15

Developing Discrepancies
Identify the core values of the patient
Determine if the patient’s current behavior is c/w or in conflict with those values
Uncover/expose discrepancies between patient’s current behavior/values and future aspirations
16

Developing Discrepancies
Assist patient to explore the negative outcomes of current behavior
Encourage discontent/discomfort that will foster change
Patient responsible for integrating facts, resolving discrepancies, building motivation to take action
17

Rolling with Resistance
Work in tandem with patient exhibiting reluctance to take action
Do not coerce or lead but facilitate greater motivation
Foster new ways of thinking about the situation
18

Avoid making recommendations or expressing bias
Patient in charge of generating solutions that are feasible, workable, given personal priorities, goals and circumstances
19

Supporting Self-Efficacy
Reinforce patient’s confidence in taking action and making behavior changes
Promote an atmosphere of optimism
Support belief that patient can perform specific tasks they set out to accomplish
21

Supporting Self-Efficacy
Reframe
Best past experiences
Vicarious experiences
Mastery Experiences:
Success breeds success!
Set SMART Goals-
S-Specific
M-Measurable
Action-based
Reasonable
Time-lined
Affirmation

Patient Centered Skills
Listening for change talk
Asking open ended questions
Reflective listening
Expressing empathy
Words of affirmation
Summarizing

Skills:Listening for Change Talk
Disadvantages of the status quo
Advantage of change

Optimism for change
Intention to change
24

Themes of Change Talk
Desire: I want, I wish, I don’t want
Ability: I could, I might, I can
Reasons: I know if I walked after work I would lose weight
Need: I need to, I should, I must
Commitment: I’m going to, I intend to
Taking Steps: I started checking my blood BG levels as you suggested
25

Asking Open Ended Questions
Reveals or clarifies what is important to your patients and their values
Discloses your patients’ feelings, fears, and beliefs about their diabetes
Can provide context for your patient’s action or lack of action
Helps you to connect with and better understand your patient
26

Reflective Listening
Reflects acknowledgment of patient intent
Patient: “I’ve really had a hard time with convincing my family that I need to have different food. They continue to buy cookies and deep fry stuff so it feels like they really don’t care. I’m so frustrated and angry about this I can’t stand it.”
27

Which Response Reflects Reflective Listening?
Diabetes Educator 1: “It sounds like you haven’t been eating the way we discussed that you should.”
Diabetes Educator 2: “You are really upset with not getting the support you would like from your family.”
Diabetes Educator 3: “I’d really be mad about this, too.”
28

Expressing Empathy
Shows that you appreciate their perspective
Patient: “Living with diabetes stinks! I can’t eat what I want, I have to take these shots, and I have to have all those pokes, and my friends treat me like I’ve got AIDS. My parents are always on my back and I just don’t feel like doing it anymore.”
29

Which Response Reflects Expressing Empathy?
Diabetes Educator 1: “I’m sorry, but you have to keep taking these shots. You know you’ll become sicker if you don’t.
Diabetes Educator 2: “You know you can really eat most anything within reason. And I’m sure your parents are just scared. They’ll let up in time.”
Diabetes Educator 3: “I think if I had something that changed my life so much, I’d be pretty angry too”
30

Words of Affirmation
Recognizes strengths and accomplishments
Thank you for …
I really like the way you …
That was a very creative way for you to …
You showed a lot of self-control in the way you …
It may not seem like much, but I think it was very impressive how you …
You have a real gift for …
31

Importance of Summarizing
Helps patients hear and understand what they are saying
Gives an opportunity to clarify understanding
Shows that you are really engaged in the communication
32

How Would You Summarize?
Patient: “I really don’t think I can follow all these new eating rules. I’ve never been able to lose weight and keep it off before, so why would I think I could do it now? I’ve probably been on a hundred diets and some worked, but I have no will power after the diet ends. That’s when it gets really bad and I start bingeing again.”
33

Which Response Is the Best Summary?
Diabetes Educator 1: “You are really frustrated with all these guidelines for eating.”
Diabetes Educator 2: “After all the efforts you have put in the frustration leaves you feeling powerless.”
Diabetes Educator 3: “So let’s see, you’ve been through a lot of diets, and some have worked and some have not, but none have helped you keep the weight off. You’re feeling discouraged, and when you’re discouraged you are likely to overeat again.” Is that right?”
34

Patient Centered Communication Styles
Directing: providing information
Guiding: exploring motivations and aspirations
Following: listening and learning about patient
We will practice these in part two!
35

Assessment Tools
Confidence/Conviction: linear scale
What to look for
Confidence or Conviction First?
Balance sheet
Pros vs. Cons
Change vs. No Change
36

Motivational Interviewing: Decisional Balance
Botelho, 2004

Willingness:
0 1 2 3 4 5 6 7 8 9 10
Confidence
0 1 2 3 4 5 6 7 8 9 10
Readiness
0 1 2 3 4 5 6 7 8 9 10
Motivational Interviewing: Self-Efficacy
Not important at all
About as important as everything else
The most important thing in my life
I don’t think I will achieve my goal.
I have a 50% chance of achieving my goal.
I will definitely achieve my goal.
I am very ready
I am almost ready
I am not ready

Incorporating MI Into Practice
Assess patient’s readiness to change a health related behavior
Use interviewing techniques and skills to help patient increase willingness to change
Explore ambivalence
If your patient is motivated to make an action plan, engage in concrete goal setting
If not, keep the conversation going, moving forward
39

Javier Part Two
How does this scenario differ from the first encounter?
What skills were used for this encounter?
How do you think the provider’s skills style and strategies effected the outcome?
https://aade.learnflex.net/CourseDepot/86/Module2/video_sr_b.html
Source: AADE

References
Prochaska, J. O., & DiClemente, C. C. (1983). Stages and processes of self-change of smoking: Toward an integrative model of change. Journal of Consulting and Clinical Psychology, 51, 390-395.
Miller, W.R., Rollnick, S. Motivational Interviewing. London: Guilford Press, 1991
Botelho, R. (2004). Motivate healthy habits: Stepping stones to lasting change. Rochester, NY: MHH Publications.

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