Health behaviour change

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Lecture given to the West of Scotland Pain Group by Dr Marie Prince, Clinical Psychologist on Wednesday 30th October, 2013.

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Health behaviour change

  1. 1. Health Behaviour Change marie.prince@ggc.scot.nhs.uk Dr Marie Prince Clinical Psychologist
  2. 2. Overview • 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
  3. 3. Learning Outcomes • 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…
  4. 4. 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 days. 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 and consistently. 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...
  5. 5. Readiness for Change • Healthcare often involves helping people to make changes. • People are in different stages of readiness for change: Stages of Change • 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
  6. 6. Components of a Behaviour Change Consultation 1. Establish rapport 2. Raise specific issue, e.g. self management 3. Assess readiness to change 4. Offer further support targeted at level of readiness to change
  7. 7. 1. Establish Rapport • Good rapport is essential for an honest discussion about behaviour change • Avoid use of certain words e.g. ‘problem’, ‘concern’ • Address other problems or concerns prior to behaviour change • Ask open-ended questions that demonstrate concern and respect for client
  8. 8. Open Questions • • • • • 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…..
  9. 9. 2. Raising the Issue: Not so Helpful Abrupt Judgmental Confrontational “You are not active, that is the problem. We really need to discuss you getting it under control”
  10. 10. 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 about that?” “I see you have not been taking your medication as prescribed lately...is there anything I can do to help with this?”
  11. 11. Guiding Principles of Communication  Advice Giving  Resist the righting reflex  Telling  Understand the client’s motivation  Persuasion  Listen  Policing  Empower the individual  Judging
  12. 12. 3. Assessing Readiness to Change
  13. 13. Stages of Change Prochaska & DiClemente (1986) Permanent Exit Maintenance Relapse Action Contemplation Decision/ Preparation PreContemplation
  14. 14. Assessing Readiness to Change Importance Why should I change? Personal values and expectations of the importance of change Costs of change Readiness Confidence How will I do it? Self-efficacy Will I cope? Can I do it? Rollnick et al (1999)
  15. 15. Formally Assessing Readiness to Change The Importance / Confidence Ruler 1 2 3 4 5 6 7 8 9 10 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
  16. 16. 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 wondering why…
  17. 17. Informally Assessing Readiness to Change Listen to the language your patient uses, to identify their readiness to change
  18. 18. Pre-contemplation, Contemplation 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.”
  19. 19. Explore Importance • 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
  20. 20. Explore Confidence To improve confidence, change must be rated as important. • Do little more • Scaling questions • Brainstorm solutions • What helped/worked previously? Re-assess confidence
  21. 21. 4. Offer Targeted Support Key Clinical Tasks at each Stage of Change
  22. 22. Precontemplation 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 you feel?’ ‘I don’t want to push you into a decision. You’ll be the best judge of whether you want to make any changes’
  23. 23. Contemplation Tipping the balance Normalise ambivalence Examine the pros and cons of change Provide encouragement & support to build confidence and give hope
  24. 24. Decision / Preparation Choosing between alternative change strategies Provide support and encouragement Offer information and options Help patients choose between alternative change strategies “What would you be willing to try?” “Which option sounds best to you?”
  25. 25. Action Help to carry out and comply with change strategies Focus on small realistic targets / Goal Setting Offer support/affirmations Reinforce convictions Check expectations are realistic to avoid sense of failure
  26. 26. Maintenance 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
  27. 27. Relapse Assist return to change process as soon as possible 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?”
  28. 28. Key Clinical Tasks • Precontemplation • Contemplation • Decision/preparation • Action • Maintenance • Relapse Raise Awareness Tip the balance Explore Ambivalence Pick a strategy Support & Inform Support progress Realistic Goals Maintenance skills Relapse planning Return to change
  29. 29. Summary • Follow the patient • Be curiously interested • Use the Stages of Change Model • Reduce clinician frustration, change is not your responsibility • Maintain rapport • Target your Intervention • Dance don’t wrestle
  30. 30. References • 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 Treatment. • 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, 7, 125-131.
  31. 31. References • Improving Health and Changing Behaviour British Psychological Society, 2008 http://www.abdn.ac.uk/healthpsychology/pub lications/Health_Trainer_Manual.pdf

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