Motivational Interviewing (MI) and the Transtheoretical Model of Health Promotion (TTM) Susan Crawford. PhD, RN, CHES Adapted from Dennis E. Elsenrath, Ed.D. National Wellness Conference 2004 Presentation on Recognizing and Responding to Resistance to Change 3/08
What Have We Tried and What Has Not Worked in Health Promotion Health Belief Model (HBM): Developed by Rosenstock and other psychologists in the 1950s to explain health choices. Based on premise that if intelligent people understand their risk and susceptibility to a health problem they will change their behaviors (hence HRAs or Health Risk Appraisals). Real world findings: Information alone is not sufficient to make and sustain healthy changes. Note doctors, nurses and others that fail to make healthy choices.
What Have We Tried and What Has Not Worked in Health Promotion Bandura’s Social Learning/Cognitive Theory: Developed by Bandura in the 1970s and 1980s. Self Efficacy —belief one can make a change using a Confidence Scale 1-10 Role Modeling —replicating prior observed behavior Person-Environment Fit and Regulatory Environment —bidirectional social factors that support change Health promotion still uses incentives (such as Tshirts) and enhances confidence with mile markers, tracking successes with food diaries and exercise logs, etc.
S = Specific M = Measurable A = Attainable R = Realistic T = Timely Social Learning Theory Albert Bandura Health Promotion/Behavior Change Strategy to Enhance Self-Efficacy Setting a Health Goal
Transtheoretical Model of Health Promotion (TTM) a theoretical model of behavior change, which has been the basis for developing effective interventions to promote health behavior change. Prochaska & DiClemente, 1983; Prochaska, DiClemente, & Norcross, 1992
Stages of Change Transtheoretical Model of Health Promotion Prochaska, Norcross, DiClemente, 1992. Readiness to Make Healthy Change Pre-Contemplation —not even thinking about making change Contemplation —considering making change in next 6 mos Preparation —getting ready to make change Action —working on making healthy change Maintenance —healthy change in place at least 6 mos
Stages of Change Supporting Healthy Changes . Supporting Healthy Change Pre-Contemplation Awareness, Supportive Environment, Helping Relationships Contemplation Involve Emotions, Enhance Awareness, Decision, Relationships Preparation Firm Commitment, Set Start Date, Action Plan, Small Steps Action Recruit Support, Mile Markers, Reward for Goal Maintenance Avoid Relapse Environments Sustained Long Term Effort (1 day at a time)
Stages of Change (Transtheoretical Model of Health Promotion) + Motivational Interviewing Techniques Decreased Resistance to Change and Increased Rapport Reference: Miller, W.R. & Rollnick, S. (2002).Motivational Interviewing. New York: The Guilford Press. _______ *Note: the CDC and WHO now use the TTM and MI in training, research, and literature for conditions ranging from diabetes management to smoking cessation to CAD risk management. NIH Guide. (2003, January 13). Maintenance of Long Term Behavioral Change. Retrieved October 31, 2007, from http://grants.nih.gov/grants/guide/rfa-files/RFA-OB-03-003.html .
Script for Stages of Change PLUS Motivational Interviewing ** Denotes key questions to move participant’s readiness to change to next level. Identify health behavior change you are considering but have not initiated or maintained How long have you considered this change? Identify external obstacles that you see in making the change. Identify internal obstacles that you see in making the change. What commitments are higher priorities? What do you like about your current behavior? What are your concerns about the new behavior? What concerns do you have if your current behavior were to change? What would you gain from adopting this health behavior? ** On a scale of 1 (low) to 10 (high) how important is this change for you? On a scale of 1 (low) to 10 (high) how determined are you to make this change? What would it take for you to move 2 points higher on the determination scale? ** What would it take for you to commit to this change? **
Resistance to healthy changes: NATURE OF RESISTANCE An absence of full commitment to participating in change.
Resistant Behaviors Predictive of Poor Outcomes Interrupting Cutting off the helper Talking over the helper
Resistant Behaviors Predictive of Poor Outcomes Arguing Challenging the helper with no constructive alternative Discounting the helper (you don’t know what you are talking about) Disagreeing Open hostility
Resistant Behaviors Predictive of Poor Outcomes Negating Minimizing or denying the problem Excusing one’s behavior Blaming others Rejecting the helper’s opinion Showing unwillingness to change Alleged impunity, pessimism
Resistant Behaviors Predictive of Poor Outcomes Ignoring Inattention Non-answer No response Sidetracking
Causes of Resistance “ Cons” still outweigh “pros” (Precontemplators or contemplators) Helper “Righting Response” (Helper’s urge to “fix” problem) Individual’s fear of criticism, judgment, failure, etc. Unwillingness to work at change (change takes effort) Displaced anger and authority issues Mistrust Learned helplessness Emotional or thought disorder Personal dislike of helper or helper characteristics (sex, race, age) Fear of losing control Belief that acknowledgment of problem a sign of weakness
Non-helpful Responses to Resistance Blaming, judging, criticizing, using sarcasm Warning of negative consequences Giving up at first sign of resistance Being too patient, fostering stagnation (especially with contemplators) Using authority to try and overpower resistance Arguing, strong confrontations Excessive questions (sounding like interrogation or parents)
Therapeutic Responses to Resistance Accept resistance as common and sometimes healthy. Develop rapport with empathy, acceptance, and genuineness. Avoid taking resistance personally. Create partnership based on respect and compassion. Offer support and encouragement. Allow individual to talk about ambivalence to change. Slowly “shape” new behavior. Help individual to form healthy social support. Reframe change into a positive challenge. Increase sense of control. Teach flexible thinking and problem solving. Consider consulting with colleagues when you are unsuccessful.