Promoting Behavior Change in 20 Min. or Less Promoting Behavior Change in 20 Min. or Less Benton Franklin County Medical Society February 20, 2015 Daniel

Promoting Behavior Change in 20 Min. or Less

Benton Franklin County Medical Society

February 20, 2015

Daniel O’Connell, Ph.D.

1816 1st Ave W, Seattle, WA 98119

206 282-1007

[email protected]

Dan O'Connell, PhD 2015

Learning Objectives1) Recognize and apply the fundamental

demeanors and behaviors of motivational interviewing

2) Assess and utilize stage of change in guiding your next move

3) Apply these strategies to typical exam room conversations about behavior change


TOOLS for CliniciansMotivational Interviewing

increase client/family self-motivation for change

Stages of Change to guide interventions by understanding

readiness to consider or take specific actions

Social Learning Theory People are most likely to attempt to do what

they are convinced is useful and what they have confidence they can carry out.


People are most willing to try change when…

They are reasonably convinced it is necessary and could be helpful

They are reasonably confident they could succeed

It is important enough to them

Commitment is the interaction of all 3 elements.


From Motivational Interviewing:

Get behavior on the agenda

Acknowledge autonomy

Provide-elicit-provide

Express empathy and normalize

Explore ambivalence

Avoid arguments Roll with resistance

Set limits on yourself rather than the clientDan O'Connell, PhD 2015

Getting behavior on the agenda

Creating an agenda that includes behavioral issues

Establishes dialogue rather than lecture

Activates client and family from the outset

Reluctance to include behavior in agenda is grist for the mill.


Agenda Setting“What behaviors are you focusing on at home to

help with this?”

“Would it be alright if we talk a bit about…”

“You seem reluctant to talk about___. Can you tell me what is going through your mind?”

“There are a number of things that you can do at home to reduce your risk of another heart attack such as diet, exercise, and quitting smoking. Which would be most helpful for us to talk more about today?”


Acknowledge AutonomyBoth parties maintain their autonomy

The patient owns the problem

Improvement comes through adherence to a mutually agreed upon plan

Active decision makers have better outcomes

Express concern not criticism or control


Acknowledge Autonomy

“Obviously this is for you to decide. I am just concerned that you will not have the outcome you want __________, unless you are able to________”

“How important is this to you?”

“”You have to decide if it is worth it.”

“It is hard to decide when you are getting different advice from varying sources.”


Provide-Elicit-Provide-Elicit

You want dialogue not monologue

Keeps client and family active

Keeps doctor on material that is relevant/of interest to the patient/family

Quickly identifies areas of disagreement and agreement for more efficiency


Provide-Elicit-Provide-Elicit“I am concerned that the diabetes will cause you

a lot of harm unless you can stick to the regimen more closely. How worried are you about that?”

“The research tells us that losing 10% of the extra weight can be helpful. What are your thoughts?”

“You are reporting all the cardinal symptoms of major depression, which would help to explain why it has been so hard for you to take better care of your health. How does that match up with what you had been thinking?”


Express Empathy and Normalize

Empathy is communicating that you can see and feel it from the patient’s perspective

Empathy is the lubricant in the conversation and in the relationship Deepens the connection as well as reducing the

friction

Normalizing is respectful and avoids universal hypersensitivity to criticism


Express Empathy/Normalize (do not agree on hopelessness)

“I know many of my patients feel put on the spot when asked about their ____________.”

“It has been tough hasn’t it.”

“Its natural to be frustrated when you have succeeded and then relapsed in the past.”

“It’s hard to imagine where you would fit more exercise into your day.” (vs. agreeing that it is impossible to fit more exercise in)


Explore AmbivalenceAmbivalence is completely normal!

Exploring ambivalence openly reduces the “Yes, but…” phenomenon Changes the structure of the conversation from

“Either/or” to “Both/and”


Explore Ambivalence“I imagine you have a number of different

thoughts and feelings about this.”

“On the one hand ____________, and on the other hand ___________”

“Part of you would like to lose weight, but another part you has lost confidence that it is possible. Tell me more about that.”


Avoid Arguing/Roll with Resistance

Arguing is a mode of discourse in which no one is listening

It corrodes the relationship poor adherence, no-shows etc.

Learn to hear the argumentative tone in your’s and the client’s voice and be ready to roll with resistance


Avoid Arguing/Roll with Resistance

“I suppose I do have a different view from you about some of this.”

“Perhaps I am making it sound too easy.”

“You’re right, there are many ways and timetables on which to proceed.”

“Tell me about steps that sound doable from your perspective.”

“I wish we did have a treatment that was less burdensome, and yet this is our most effective approach at the moment.”


Compassionate Limit Setting(on yourself first)

Frame limits in terms of restrictions on your own behavior rather than theirs. Creates less conflict and accusation Affirms your right to autonomy as a doctor

Anchor your opinion within your profession Providing a more objective, less personal standard

than “I am uncomfortable____.”


Compassionate Limit Setting “In light of what we know already, this

doesn’t feel like a safe enough plan to me.”

I will have to stop for now as I know there are people waiting to see me. Could we agree to pick this up again _____________?”

“I think we have reached an impasse on this. Would you like to get an opinion from another clinician to compare approaches?”

“There are 3 criteria we use to decide on that. Would it help if we went over them together and see where we stand?”


Stages of ChangePre-contemplation

Contemplation

Preparation/Commitment

Action

Maintenance Maybe even complete resolution

Relapse J. O. Prochaska and Carlo DiClemente


Strategies for Pre-contemplator

Ask them to think about this (contemplate) with you Request permission to discuss

Ask questions before giving lectures “What do you think about….”

Focus on data as well as conclusions “There is some evidence that suggests…”

Contrast goals with behaviorDefine your boundaries as part of your

“practice” Acknowledge when an impasse is reached


Strategies for ContemplatorsElicit perspective: empathy & curiosity

Conviction and confidence

Soften all or nothing thinking “One day at a time”, improvement rather than cure

Explore alternatives

Identify pros and cons of problem and of potential solutions

Elicit self-motivational statements “And why would that be important for you?”

Suggest experiments


Strategies for Preparation/Commitment

Clarify program, timetable and others’ involvement Referrals, prescriptions, boundaries

Support appropriate self-efficacy While empathizing with doubts

Support family’s right to fully functioning member

Plan for f/u, including “any outcome”


Strategies to support ActionInterest equals encouragement

Adjust plan for greater success Help identify /overcome obstacles

Anticipate and address early slips

Coordinate with others involved Adherence is precarious without coordination

Schedule follow-up contacts to match support to need


Strategies for MaintainerYour interest still equals re-enforcement

No news is not good news

Differentiate slip from relapse Early recognition and recovery is easiest

Explore expectations: met/unmet?

Be vigilant for need to intensify action But have a maintenance support schedule in place

even if things are going well.


Strategies for RelapseExplore last change attempt

Don’t settle for facile, “It didn’t work…”

Identify success as well as setback If they got to relapse it means they were able to

take some action successfully. How did they do it?”

Frame as learning opportunity Suggest another attempt is inevitable

“You have already concluded once that this was important.”

Elicit original reasons for change “Remind me why you felt that quitting drinking

was important when you tried to stop the last time?”


Putting It All TogetherWe influence clients to see themselves in

a process leading to change.

The client’s success takes time during which motivations converge, knowledge, attitudes and skills are developed and “experiments” are tried and persisted at until improvement is obtained and a new self perception emerges that supports long term maintenance of the most constructive outlook and behavior.


Reading IdeasO’Connell, D. (2014). Behavior Change. In Behavioral

Medicine: A guide for clinical practice 4th Edition. MD Feldman and Christensen JF eds. Lange: McGraw Hill, Pages 185-194.

Prochaska JO et al Changing for Good . Guilford. 1994 Rollnick S et al. Motivational interviewing in

healthcare: helping patients change behavior. 2007 Guilford Press.

W. R. Miller & S. Rollnick, Motivational interviewing: Helping people change (3rd. edition New York: Guilford Press. 2013

Baumeister RF and Tierney J. 2011. Willpower. Penguin Press, New York

Google for “Motivational Interviewing”


Documents

Promoting Behavior Change in 20 Min. or Less Promoting Behavior Change in 20 Min. or Less Benton Franklin County Medical Society February 20, 2015 Daniel