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.
The Transtheoretical Model of Behavior Change Stages of Behavior Change Prochaska, J.O., & DiClemente, C.C. 1983
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
Behavior Change Motivational Interviewing: A client-centered, directive method for motivating change by exploring and resolving ambivalence. Encourages change talk Discourage resistance talk Miller and Rollnick, 1991
Creates a partnership instead of expert/recipient roles
Miller and Rollnick, 1991
Guiding Principles: Express Empathy Avoid Argument Develop Discrepancy Roll with Resistance Support Self-Efficacy Motivational Interviewing Miller and Rollnick, 1991
Motivational Interviewing: Empathy Empathy IS: the act of understanding, being aware of, being sensitive to and vicariously experiencing the feelings of another. Empathyis NOT:. Pity: a sorrow for one suffering, distressed or unhappy Sympathy: an affinity, association or relationship between persons or things wherein whatever affects one similarly affects the other.
Motivational Interviewing: Empathy Do these statements express empathy, sympathy or pity? “I feel sorry for you.” “I respect your pain.” “I feel your pain/joy.”
Motivational Interviewing: Empathy How to do it: Unconditional positive regard: Every situation may not be acceptable, but every person is. Express feelings, not thoughts: Thought: “I feel like a failure.” Feeling: “I feel sad.” Identify needs, not strategies: Strategy: “You need to lose weight.” Need: “You are going to lose weight so that your need for physical well-being is met” Relay observations, not evaluations Evaluation: “You failed to exercise last week.” Observation: “You went to the gym one time last week”
Motivational Interviewing: Develop Discrepancy Determine if current behavior aligns with long-term goals/motivators Encourage discontent/discomfort Sitting in the “muck” will foster change Open ended-questions (OEQ) More than 50% of all questions using MI should be OEQs. Examples: What is the best experience you have had with (future desired behavior)? What concerns you about your current behavior? What values do you seek to represent in your life? What changes would you like to make in your routine?
Reflective Listening Ratio of OEQs to reflections: 1:2 Four types: Simple Reflection: Patient: “I don’t have time to exercise.” Educator: “I hear you saying you don’t have time to exercise.” Amplified Reflection: Patient: “I don’t have time to exercise.” Educator: “It is impossible for you to fit exercise into your schedule.” Motivational Interviewing: Develop Discrepancy
Double-Sided Reflection: Patient: “I don’t have time to exercise.” Educator:“I hear you saying you don’t have time to exercise. But I have also heard you say that exercise makes you feel better and that regular exercise would be good for your energy and health.” Shifted-Focus Reflection: Patient: “I don’t have time to exercise.” Educator: “Since you don’t have time to exercise, let’s talk about the dance class that you started with your friend. I remember you saying you enjoyed the class. Motivational Interviewing: Develop Discrepancy
Motivational Interviewing: Rolling with Resistance
Motivational Interviewing: Self-Efficacy “Whether you think you can or you can’t, you’re right.” ~ Henry Ford Reframe Patient: “I have tried lots of times to lose weight and always fail.” Educator: “First, congratulations on realizing there is an aspect of your life you want to change and being motivated to keep going under difficult circumstances! Just by being here, you are willing to accept help in achieving your goals.” Best past experiences What has been your best experience with xxx? What strengths can you bring to the table towards achieving your goal of xxx? What helped you achieve this in your environment? Vicarious experiences Who can you relate to who has been successful with xxxx?
Mastery Experiences: Success breeds Success! Weekly Goals: Set goals based on TTM stage of change S.M.A.R.T goals are:
Affirmation Your certainty of their success should be > than his/her doubt. Motivational Interviewing: Self-Efficacy
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 will definitely achieve my goal. I have a 50% chance of achieving my goal. I am very ready I am almost ready I am not ready
Based on patient’s response ask, Why didn’t you choose a lower number? What would it take to get you from a “5” to a “7”? Motivational Interviewing: Self-Efficacy
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.