Presentation on theme: "How to motivate people in three minutes"— Presentation transcript:
1How to motivate people in three minutes The SCIP TechniqueHow to motivate people inthree minutes
2Today’s Training Three Minute Motivation The New Conversation Behaviour Change ABCThe SCIP TechniqueSkills RehearsalSweet and Sour Takeaway
3Three Minute Motivation Motivational Interviewing is an evidence based intervention. It is a useful tool that has never been needed more. We are faced with a growing health crisis. Changing unhealthy lifestyles is an essential part of reducing health inequalities and closing the life expectancy gap. However Motivational Interviewing takes time: to learn and deliver. We don’t always have the time and resources available. We need to be able to have effective conversations about change that are easy and quick to deliver. We need to make the skills and techniques of motivational interviewing as accessible to as many people as possible. We need a “new” conversation!
4SCIP The New Conversation The SCIP technique is a four step conversational framework that is designed to enhance motivation and empower behaviour change.It uses specially designed materials: SCIP charts.It uses recognised motivational and behavioural techniques.It has been designed with time pressured environments in mind.Easy and accessible to different groups – health professionals or peersSensitive to time:Easy to learn 2 to 3 hours rather than 2 to 3 daysEasy to use: 2 to 3 minutes
5SCIP The New Conversation So is SCIP the “new conversation” we’ve been waiting for?
6Behaviour Change ABC A: Ambivalence B: Beware the “Righting Reflex” C: Change ConversationsAdapted from “Motivational Interviewing in Health Care”by Rollnick, Miller and Butler
7A: Ambivalence “To want to and not want to at the same time…” No ChangeChangeAmbivalenceWhat’s bad about nowWhat’s good about nowWhat’s good about changeWhat’s bad about changeThe Inner Conflict: most people are aware that some changes are good for them – they know good reasons to change. Most people are also comfortable with their usual routines and change requires some effort and sometimes discomfort (exercising for the first time in a while, nicotine withdrawal, losing a social life centred around an unhealthy behaviour) – they know good reasons to stay the same (not change). The default position is status quo – inertia – stay the same.The usual pattern is: think about the reasons to change, then counter that with a reason not to change and ultimately: do nothing. They become stuck in AMBIVALENCE.There is an inner conflict:Reasons Not To Change Reasons To ChangeReasons To Stay the Same v Reasons Not To Stay the SameThere are things that can happen that move the person in one direction or the other: making change more or less likely. When we are motivating a behaviour change we are trying to guide people towards the “change side” and as a result make change more likely. We need to be aware that there are things that we do that move them in the opposite direction – so despite our best efforts making change less likely.“To want to and not want to at the same time…”
8Exercise One - Inner Conflict Reasons not to changeReasons to changeReasons to stay the sameReasons not to stay the sameExercise One: Understanding AmbivalenceThis exercise is to highlight the two sides of the inner conflict. Think of something that you could change. This can be anything! Complete Box 1 (below).Once you have completed the box – are you more or less likely to change? Or are you still Ambivalent?
9B: Beware the Righting Reflex No ChangeChangeAmbivalenceWhen we are talking to people about change we are doing so because we see what good the change will do. We understand why stopping smoking or doing more exercise would be good. We are trying to “help” them. For some of us that’s our job! We explain carefully why change is good, why staying the same is bad and offer helpful suggestions of how they might do it. We do a good job!
10B: Beware the Righting Reflex No ChangeChangeAmbivalenceWhat happens? Sometimes it works, sometimes (often) we find ourselves “banging our heads against a brick wall”. Why? We’ve used the Righting Reflex and fallen into the “yes but, no but” trap.The “Righting Reflex” is our natural approach to helping people we care about – our patients or friends and family. We try to make it “right”. Why doesn’t this work?Let’s go back to Ambivalence. There are two sides – the “change” side and the “don’t change” side.By using the righting reflex you are taking the “change” side. The natural reaction of the person you are talking to is to balance this out and take the other side – the “don’t change” side! If someone pushes you in one direction the natural tendency is to push back in the other! So whilst you are describing passionately all the good reasons for change and all the simple ways it can be done, the other person (the person who needs to change) is describing all the reasons why change is hard for them and why each suggestion you offer (whilst good for someone else) is no good for them. They are arguing against change, are moving towards the “don’t change” side of their inner conflict and as a result are less likely to change. You are having a “yes but, no but conversation”!
11B: Beware the Righting Reflex No ChangeChangeAmbivalence“Yes but, no but”What happens? Sometimes it works, sometimes (often) we find ourselves “banging our heads against a brick wall”. Why? We’ve used the Righting Reflex and fallen into the “yes but, no but” trap.The “Righting Reflex” is our natural approach to helping people we care about – our patients or friends and family. We try to make it “right”. Why doesn’t this work?Let’s go back to Ambivalence. There are two sides – the “change” side and the “don’t change” side.By using the righting reflex you are taking the “change” side. The natural reaction of the person you are talking to is to balance this out and take the other side – the “don’t change” side! If someone pushes you in one direction the natural tendency is to push back in the other! So whilst you are describing passionately all the good reasons for change and all the simple ways it can be done, the other person (the person who needs to change) is describing all the reasons why change is hard for them and why each suggestion you offer (whilst good for someone else) is no good for them. They are arguing against change, are moving towards the “don’t change” side of their inner conflict and as a result are less likely to change. You are having a “yes but, no but conversation”!
12Exercise Two (Pt.1) – ‘Yes But, No But’ Changer: “A good reason to change is…..” Helper: “Yes but….” Is this kind of conversation familiar?“Yes but, no but”Exercise Two: The “Yes But No But” GameThis exercise is to highlight the consequences of the “righting reflex”.In pairs, look at a “Box 1” (pick one from the pair) that you completed in the previous exercise. Choose a role: Changer or Helper. The Helper goes first – from the chosen Box 1 describe one of the reasons for change. Start with “a good reason to change is....” The Changer then answers with “Yes but” and then describes the reason not to change on the other side of the box.Work your way down the table – each taking turns: Helper then Changer.At the end think about how each of you is feeling:How is the helper feeling? Is the changer feeling more or less likely to change?Swap over roles and repeat the exercise using the other person’s box 1.You have had a “yes but no but” conversation.Is this kind of conversation familiar?Think about how we might do things differently?
13C: Change Conversations Think about how we might do things differently?Ask rather than adviseListen more and talk lessWe understand the inner conflict of ambivalence and how our natural desire to help and make it “right” can actually frustrate us. So how do we move people on – away from status quo and towards change? We need to have change conversations! The “righting reflex” can frustrate us because the wrong person is talking about change. We need to swap roles and have a change conversation. A change conversation is a way of getting the right person talking about change. The difference between the righting reflex and a change conversation is subtle but important and it is down to what you do:You ask rather than adviseYou listen more and talk less
14C: Change Conversations No ChangeChangeAmbivalence“Change Conversations”Ask Rather than Advise: With the righting reflex we offer advice and help to people. We advise them why change is good and staying the same is bad. We offer useful suggestions to make change easier. In a change conversation we ask people what they think:Why do they want to change?What is it about staying the same they don’t like?How could they change?Why is change important to them?How would things be better if they managed to change?Given the opportunity and encouragement most people will answer your questions and describe the “change” side of their inner conflict. They will Change Talk. Change talk is the expression of the thoughts, feelings and values of the person that will drive the change. If you can get people to change talk you are moving the balance of the inner conflict towards change. You are making change more likely!Listen More, Talk Less: A conversation is a two way street – both people need to have the opportunity to talk and listen. If one person does all the listening and the other does all the talking is it a conversation? For effective behaviour change we need to get the balance right between talking and listening. If you are doing all the talking you are not leaving any room for the other person to “change talk”. Equally if you just sit listening, the usual pattern of “reason to change, reason not to change, do nothing” is the most likely result. For effective behaviour change we need to have a balanced conversation that encourages and allows change talk and keeps the momentum moving towards change.
15C: Change Conversations Ask “Open questions….Summarise…..The key skills for a good change conversation: ask open questions (explain and demonstrate if needed – yes/no game and highlight the “W” questions) that generate change talk! Listen for the desire, ability, reason and need to change. These will be the personal values that will fuel the change.An effective change conversation has been likened to taking a walk through a field of flowers. Think of each piece of “change talk” as a flower. As you wander through the meadow collect as many flowers as you can. The better you are at listening the more flowers you will find. Once you have enough flowers gather them then together to make a bouquet. Give the bouquet to the person you are walking (or talking!) with. In a change conversation you can generate change talk by asking “open questions”. Summarising their change talk back to the person is a powerful way of guiding them towards change.
16C: Change Conversations Remember the inner conflict: Changer: “....I’m worried that I won’t see my mates.....I’m not sure I can do this...” Helper: “change is often difficult and there are always reasons to stay the same but let’s go back to what you just said a moment ago.....”Remember the inner conflict:During change conversations the person you are talking to will sometimes express thoughts and feelings more suited to the other side of their inner conflict: worries, concerns and doubts. It is important to acknowledge these without reinforcing them. Don’t argue against them and certainly don’t try and make them “right” (or you could get trapped in a “yes but, no but” conversation). Acknowledge that they exist, empathise (that change is often difficult) and re-emphasise the “change talk”. “Develop the Difference” is a simple technique that can be used at this point can get the momentum back!This takes training and practice – especially to do it well and be time efficient. The SCIP technique helps you have effective and time efficient “change conversations”. Additional training is needed and available if you want to go beyond the SCIP technique.
17“Change Conversations” Exercise Two(Pt.2)What is it about staying the sameyou don’t like?How would things be betterif you managed to change?How could you change?Think about how this conversationis different.“Change Conversations”In your pairs and again using box one – practice having a change conversation.Try some of the following questions to illicit change talk:Why do they want to change?What is it about staying the same they don’t like?How could they change?Why is change important to them?How would things be better if they managed to change?Summarise and hand back your “bouquet”
18D: Develop the Difference If their current behaviour threatens a firmly held belief or value this is a very powerful incentive to change. This is Change Fuel – and we need to use it!So far we have discussed the inner conflict of ambivalence, described how our natural righting reflex can take us in the wrong direction and explained the important parts of a change conversation. Now we are going to consider a very simple but important tool for keeping the momentum moving towards change and in so doing helping us resist the screaming urge of the “righting reflex” that might be going off in our heads!By asking some simple open questions we will (hopefully) understand more about the “inner conflict” (change or not to change) of the person you are talking to. You will have identified some of the things that are really important to them – their beliefs and values. If their current behaviour threatens a firmly held belief or value this is a very powerful incentive to change. This is Change Fuel – and we need to use it!
19D: Develop the Difference “it’s interesting to think isn’t it that on the one hand being less out of breath when you play with the kids is really appealing to you… …on the other your smoking is the major reason why you are out of breath. What do you think of that…..?”Example: By asking some simple open questions as part of a change conversation we found out that Bill (who smokes 20cpd) likes the idea of playing with his children without getting short of breath. He would also like to be able to play with his grandchildren in the same way one day. There is a difference here – he wants to be healthier and yet smoking is making him less healthy. He wants to play with his grandchildren and yet smoking increases his risk of premature death. By highlighting this difference (or discrepancy) we can pour fuel on Bill’s desire to change. The key difference here is we are not telling him to stop smoking because it is making him short of breath or is increasing his risk of not being alive when he has grandchildren – this is the “righting reflex” and would reverse the momentum leading us to a “yes but, no but” conversation. We are pointing out the difference between what is important to him and what he is currently doing.
20“Change Conversations” Exercise ThreeChanger: “....it’s not that easy though is it; smoking helps me deal with the stress of being out of work....”No ChangeChangeAmbivalence“Yes but, no but”“Change Conversations”Exercise Three: Developing the DifferenceThis exercise is an opportunity to practice a simple but very effective skill. In pairs choose who will be the Changer and who will be the Helper.Our Changer is a smoker who admits to doing very little exercise. During a change conversation they expressed some concerns about lung disease and getting out of breath and they liked the idea of having a bit more money in their pocket. All was going well until:Changer: “....it’s not that easy though is it; smoking helps me deal with the stress of being out of work....”The Helper needs to get back on track. How do they do it?In your pairs practice developing the difference. The Changer can respond however they wish.Swap roles and try it in a different way. Discuss together how each of you felt.
21E: Empower CommitmentChange is more likely if we empower people to come up with their own ideas.It can be helpful to offer people some options of what “other people have tried”Helper: “here are some things that other people have found helpful when they decided to quit…..what would work for you?”E: Empower CommitmentWe have discussed the inner conflict, how to give room for a change conversation and how to gather together the change talk and use it to tip the balance towards change. The next stage in the change conversation is to Empower Commitment. Let’s look at the two parts separately:Empower: the outcomes of what you are trying to achieve will be more effective if the patient takes charge of what they do next. They are experts in their own lives. It is they who will have to “fit in” any change. Successful change that sticks needs to be personal and easy. The change needs to become normal. Only by empowering the patient with the information and resources needed can they make successful change. It is useful to be able to offer a range of options “of what other people have found helpful” but always combined with open question “what would work for you?”Again the Righting Reflex is strong at this point and comes disguised as “helpful suggestions”. The outcome is the same! We reverse the momentum and get stuck in “yes but, no but”.Compare these two scenarios:Helper: “you could use patches….”Changer “yes but I’ve tried them and I got a rash”Helper: “what about the inhalator….”Changer: “yes but my mate used that and it didn’t work…”Or:Helper: “here are some things that other people have found helpful when theydecided to quit…..what would work for you?”Changer: “well I don’t like the idea of a patch – the last time I got a rash. John at worksaid the inhalator was rubbish. I fancy this tablet…..can you tell me about that?”
22I could…..I should……I might E: Empower CommitmentNo ChangeChangeAmbivalenceI could…..I should……I mightI WILLCommitment: So far we have discussed the intention form of change talk: “I could, I need to, I want to”. We need to guide the patient towards making a commitment: “I will”. The timing of this is crucial: the person needs to be “empowered” enough to be able to make a commitment to change. Too early and they will feel pushed and push back (moving away from change), too late and they will settle back into the comfort of the status quo.People may naturally move on to “commitment talk” as part of a change conversation “I will…” “I am going to….”Others might need a gentle push:Helper: “are you ready to move on to agree what you will do…or do you need more time to think about this?”Research has shown that people who express the detail (what, where, when, who with) of what they “will do” are much more likely to do it. Time spent encouraging someone to tell you what they plan to do is much more productive than getting them to agree to your plan.
23One Problem!How do we have an effective “change conversation”, that moves the person out of ambivalence and towards change in a busy setting without using the righting reflex to manage the time?We have spent time look at the ABCDE of Behaviour Change. We understand the basic principles. The next step is to put it into practice.Problem: How do we have an effective “change conversation”, discover what will fuel the change, empower the patient and move them towards commitment in a busy setting without using the righting reflex to manage the time?Answer A: You won’t alwaysAnswer B: You do more training and skills practice in Motivational InterviewingAnswer C: You use the SCIP technique
24The SCIP TechniqueSHARE the risks COMPARE to the benefits discuss IDEAS make a PLANNo ChangeChangeAmbivalenceI could….I should……I might…I WILLThe SCIP technique is a simple four step process: SHARE the risks, COMPARE to the benefits, discuss IDEAS, and make a PLAN. It uses bespoke “SCIP Charts” designed to generate effective Change Conversations. The technique guides the changer from ambivalence through intention to commitment. It is designed to be time efficient and with a small amount of practice can deliver results in three minutes.
25SCIP Charts SCIP Charts: The SCIP charts are created for a specific behaviour change. They give examples of the risks of the current behaviour (the reasons not to stay the same), benefits of the new behaviour (the reasons to change) and ideas that other people have “found useful” when considering this change. The content is age, sex and behaviour specific. The examples are offered to stimulate the changer and generate change talk. What stimulates change talk in a teenage boy will be different from what stimulates change talk in a middle aged woman. So the examples offered to each group are different! By asking specific open questions and using the charts as prompts we can generate change talk quickly and efficiently.
26Share the Risks No Change Change Ambivalence What’s bad about now By asking the changer to think about the risks of their current behaviour we are asking them to consider their reasons not to stay the same (remember this from exercise one). Their attention is on the “change” side of their inner conflict. They are thinking and talking about change. We are having a change conversation! By keeping the content age and sex specific we are more likely to hit on something that “matters” to the changer. The conversation is about them and not people with whom they have nothing in common. The more they tell us about what they think the more likely we are to get the change fuel we need: the difference between values and behaviour.“Here are some of the down sides (risks) of what you are doing…..which stand out for you?”
27Compare to the Benefits No ChangeChangeAmbivalenceWhat’s bad about nowWhat’s good about changeThe next stage of the SCIP technique is to compare the things the changer doesn’t like about their current behaviour to the benefits of the new behaviour. These are their reasons to change. By comparing one to the other we are keeping the momentum of the change conversation going in the right direction. We are making sure that the changer is considering the things they want more of -not just what they want less of. This re-focussing on the positives is essential. The more positive the changer is the more likely they are to think that the change is a good thing and the more likely they are to take positive action. Another reason to move onto “benefits” is to focus on the “right positives”. When presented with negatives the natural reaction of some changers is to balance the conversation by talking about positives. If left to chance the changer is likely to talk about the “wrong” positives: the good things about their current behaviour. This would move the inner conflict away from change.Again we are trying to find out what “matters” to the changer – what attracts them most about the new behaviour. It will be the combination of things they want less of and things they want more of that will drive the change. Change is hard; sometimes painful it has to be worth it....to the changer!Helper: “Compare those to some of the good things (benefits) about changing…..which appeal to you?”After we have shared the list of risks and compared them to the list of benefits we summarise the change talk and offer it back to the changer – like giving them a bunch of flowers! We then develop the difference: on the one hand what they want less of (risks) and more of (benefits) and on the other their current behaviour that is making getting what they want less likely.Helper: “It’s interesting to think isn’t it that on the one hand you are concerned about some of these things and on the other you continue to do something that makes them more likely to happen?“Compare those to some of the good things (benefits) about changing…..which appeal to you?”
28Discuss Ideas I could…. I should…… I might…. No ChangeChangeAmbivalenceI could….I should……I might….Sharing the risks and comparing the benefits will stimulate a powerful change conversation (as long as we’ve resisted the righting reflex). We’ve summarised and developed the difference. The changer should be full of good intentions and understand why making the change is important for them. Now we need to empower commitment.The ideas on the SCIP chart are age, sex and behaviour specific. They are genuine examples of what similar changers have found useful. We use the list as a prompt and not an all or nothing list of options. Ideally the changer will come up with their own ideas. In so doing they will start to see the change becoming more achievable and their confidence will increase.Remember it is their ideas that are important not yours: Beware the righting reflex!Helper: “Here are some ideas that other people have found useful when thinking about this change……what do you think?”“Here are some ideas that other people have found useful when thinking about this change……what do you think?”
29Make a PlanNo ChangeChangeAmbivalenceI willThe inner conflict is firmly heading towards change. At this point you need to make the call: is the changer ready to make a plan? Some changers will naturally move from “intention” change talk (I should, I could, I need to) to “commitment” change talk (I will, I am going to). These people are ready. Gently guide them to a specific plan covering the 4Ws: what, when, where and who with!Others might need a gentle nudge with some empowerment and empathy:Helper: “This change is hard but it sounds like you have lots of ideas that I’m sure you can do…which one are you going to try first…….tell me more about it”Getting the changer to confirm their plan right at the end reinforces it in their mind and has been shown to make change more likely to happen:Helper: “Tell me again exactly what you plan to do....just so I am clear”“you have lots of ideas that I’m sure you can do…which one are you going to try first…….tell me more about it”
30Make a PlanNo ChangeChangeAmbivalenceI’m not sureWhat happens if they don’t make a plan?Not everyone will be ready to make a plan by the end of the SCIP. Don’t worry. By having a change conversation you have moved them towards change. You will have stimulated thoughts and feelings that make change more likely at some point. The most popular psychological theories of behaviour change agree that the more often someone thinks about the consequences of their behaviour the more likely they are to change. Every little bit helps!At this point you can still “empower commitment” by using active language:Helper: “It sounds like you still have some thinking to do. This change isn’t going to be easy but it sounds like there are some good reasons to give it a go……have a think about what your next steps are…I’d be interested to hear about what you did.”But you can also undo all your good work: continue to resist the righting reflex. The last thing you want to hear at this point is “yes but, no but”!“It sounds like you still have some thinking to do. This change isn’t going to be easy but it sounds like there are some good reasons to give it a go……have a think about what your next steps are…I’d be interested to hear about what you did.”
31SCIP: Skills Rehearsal SCIP: DemonstrationDave is a 43 year old with a CVD risk factor of 27% during his Health Check he disclosed he drank 8-10 units of alcohol 3 to 4 times a week.SCIP: Skills Rehearsal
33Sweet and Sour Takeaway What have you enjoyed?What have you not liked?What will you take away?
34Reflection If the change you were going to make was ‘to have a new conversation with patients about their behaviour change using SCIP’What would be your reasons:Not to change?To change?To stay the same?Not to stay the same?