Dr Marie Prince
Readiness for change
Components of a behaviour change consultation
1. Establishing rapport
2. Raising difficult issues
3. Assessing readiness to change
Stages of Change
4. Offer Targeted support
Key Clinical tasks
New skill to help patients
Increased awareness of patient barriers to change
Increased awareness of role of HP in change
Ability to link knowledge with patient stage of change
Ability to exercise caution with the use of advice
Improved “mutuality” in clinical work with patients
• Getting the spirit of the technique…
An unhelpful conversation
Clinician: Have you thought about doing more activity?
Client: Yes, many times, but I can’t seem to manage. I am so worried
about injuring myself again. I’m stuck in the house so much these
Clinician: It would certainly help your pain level.
Client: I know, but what can I do, it really hurts when I try to walk more.
Clinician: I have already told you about pacing and building up slowly
Client: Yes but what sort of difference will that make?
Clinician: Over time, you can build it up, learn how much you can
tolerate and start from there.
Client: No, I either do what you tell me and end up in pain or just stay
home and rest, altough even then I am stilll in pain.
Clinician: Yes, but…..
Client: Yes, but...
Readiness for Change
• Healthcare often involves helping people to make changes.
• People are in different stages of readiness for change: Stages of
• People can be ‘prescribed treatment’ when they are not ready,
willing or able to commit: Advice fatigue
• People need different kinds of help depending on where they are in
the cycle of change
• Key task is to determine how ready people are to change and to
move them through the process
Components of a Behaviour
Raise specific issue, e.g. self management
Assess readiness to change
Offer further support targeted at level of readiness to
1. Establish Rapport
• Good rapport is essential for an honest discussion about
• Avoid use of certain words e.g. ‘problem’, ‘concern’
• Address other problems or concerns prior to behaviour
• Ask open-ended questions that demonstrate concern
and respect for client
Tell me more about…
May I ask you about…?
What concerns you most about…?
Why might you want to become more active?
If you were to try to manage your pain, how might you
go about it?
• What do you think you might do now?
• How can we support you in…..
2. Raising the Issue: Not so Helpful
“You are not active, that is the problem. We really need to discuss you getting it
Raising the Issue: Helpful
Be honest about own agenda
Invite person to express views on subject
Ask permission to discuss topic
“Would you mind spending a few minutes talking about your [this condition] and
whether it might be worthwhile making some changes?
“[This condition] is sometimes linked with your mood/activity level/smoking. I
wonder how you feel this is relevant to you?”
“I notice you have missed a few appointments recently……..how do you feel
“I see you have not been taking your medication as prescribed lately...is there
anything I can do to help with this?”
Guiding Principles of
Resist the righting reflex
Understand the client’s
Empower the individual
Assessing Readiness to Change
Why should I change?
Personal values and expectations
of the importance of change
Costs of change
How will I do it?
Will I cope?
Can I do it?
Rollnick et al (1999)
Formally Assessing Readiness to
The Importance / Confidence
How important is it for you to engage in self
management/activity at this time? (or smoking/drinking levels)
If you decided right now to make changes to your activity
levels, how confident are you that you would succeed?
The response can elicit CHANGE TALK
• Scaling Questions
– Why 6 and not 1 for confidence?
– What would it take to be a 7
– A 2 for importance if fairly low, I am
Readiness to Change
Listen to the language your
patient uses, to identify their
readiness to change
Preparation, Action, Maintenance
“I’m trying hard not to slip back into old habits but it takes a lot of effort”
“I have decided to try to reduce my medication after Christmas”
“I do too much as it is. I don’t need to work on my exercise”
“I would like to work on the mindfulness techniques BUT it’s difficult
and I am so worried that there is a serious problem with my neck, it
is sore and I keep getting tingling.
“I know it’s a slow process but I’ve managed to swim a couple of times
and I am pacing my walking every day.”
• Don’t do anything
• Scaling questions
• Pros & Cons
• Of change
• Of status quo
• A look over the fence
• What would change feel like
• Be curious
To improve confidence, change must be rated as important.
• Do little more
• Scaling questions
• Brainstorm solutions
• What helped/worked previously?
4. Offer Targeted Support
Key Clinical Tasks
Stage of Change
Raise awareness of a problem
Ask permission to give information if this will not damage rapport;
risks o fmedication use/surgery; alcohol & benefits of change;
rationale for self management
Close discussion but keep door open:
‘Perhaps now isn’t the right time to talk about this. How do
‘I don’t want to push you into a decision. You’ll be the best judge of
whether you want to make any changes’
Tipping the balance
Examine the pros and cons of change
Provide encouragement & support to build confidence
and give hope
Decision / Preparation
Choosing between alternative change
Provide support and encouragement
Offer information and options
Help patients choose between alternative change
“What would you be willing to try?”
“Which option sounds best to you?”
Help to carry out and comply with
Focus on small realistic targets / Goal Setting
Check expectations are realistic to avoid sense of failure
Develop new skills to maintain change
Differentiate between lapse and relapse
Identify high risk situations e.g. flare up
Strategies for coping with setbacks
Reinforce importance of accepting chronic pain, not
looking for a cure
Assist return to change process as soon
Acknowledge the difficulties of change over time
Provide hopeful and empathic support
Reframe as a ‘learning experience’
Provide support with problem solving:
“What were the positive changes you previously made?”
“What was difficult about it?”
Key Clinical Tasks
Tip the balance
Pick a strategy
Support & Inform
Return to change
• Follow the patient
• Be curiously interested
• Use the Stages of Change Model
• Reduce clinician frustration, change is not
• Maintain rapport
• Target your Intervention
• Dance don’t wrestle
• Cooper, Z., Fairburn, C.G & Hawker, D.M. (2003) CognitiveBehavioural Treatment of Obesity. The Guilford Press.
• Hunt, P. & Hillsdon, M. (1996) Changing Eating & Exercise
Behaviour. Blackwell Science.
• Miller, W.R & Rollnick, S. (2002) Motivational Interviewing:
Preparing People for Change. (2nd edition). The Guilford Press.
• Miller, W.R. (1999) Enhancing motivation for change in
substance abuse treatment. (Treatment Improvement Protocol
[TIP] series no. 35). Rockville, MD: Center for Substance Abuse
• Rollnick, S., Mason, P. & Butler, C. (1999) Health Behavior
Change: A Guide for Practitioners. Elsevier Limited.
• Stott, N & Pill, R.M. (1990) ‘Advise Yes, Dictate No’. Subjects’
views on health promotion in the consultation. Family Practice,
• Improving Health and Changing Behaviour
British Psychological Society, 2008