Stages of Change and Motivational Interviewing

Behavior Change  Behavior change is rarely a single event.  Many times we encounter patients who seem unable or unwilling to change even after a crisis event.  During the past decade, we have come to understand that behavior change passes through identifiable stages – called The Stages of Change

Stages of Change  Stage 1 Pre-contemplative  Stage 2 Contemplative  Stage 3 Preparation  Stage 4 Action  Stage 5 Maintenance & Relapse Prevention

Stage One: Precontemplation  During the precontemplation stage, patients do not even consider changing.  Smokers who are “in denial” may not see that the advice applies to them personally.  Patients with high cholesterol levels may feel “immune” to the health problems that strike others.  Obese patients may have tried unsuccessfully so many times to lose weight that they have simply given up.  Their position is “I don’t have a problem” OR “I have tried and failed so many times why bother”

Stage Two: Contemplative  During the contemplation stage, patients are thinking about change but are ambivalent “I know I need to change but…..”.  They may feel a strange sense of loss even though they understand the gain.  During this stage, patients assess barriers (e.g., time, expense, hassle, fear, “I know I need to, doc, but …”) as well as the benefits of change.

Stage Three: Preparation  During the preparation stage, patients prepare to make a specific change.  They may experiment with small changes as their determination to change increases.  For example, sampling low-fat foods; calling a treatment center for information.  Switching to a different brand of cigarettes or decreasing their drinking may signal that they have decided a change is needed.

Stage Four: Action  The action stage is the one that most physicians are eager to see their patients reach.  Patient is actively changing – stopped smoking, maintaining a new health diet, etc.  Talk is over – now it’s action.  Encouragement and support is needed  Patient mood is usually lifted during this stage.

Stage Four  Many failed New Year's resolutions show that if the prior stages have been glossed over than action itself is often not enough.  Any action taken by patients should be praised because it demonstrates the desire for lifestyle change.  Can you see the conflict that can arise when we do not meet a patient where they are?

Stage Five: Maintenance & Relapse Prevention  Maintenance and relapse prevention involve incorporating the new behavior “over the long haul.”  Discouragement over occasional “slips” may discourage the change process and result in the patient giving up.  However, most patients find themselves “recycling” through the stages of change several times before the change becomes truly established.

Quiz Time  You have a new client, Mrs. Apple. She was recently diagnosed with Type II Diabetes. The physician advises her that if she can lower her Body Mass Index to the normal range, her glucose levels will be normal and stable. When you visit Mrs. Apple, she doesn’t see her weight as an issue. According to her, “she is only a little heavy but she is thinner than her sisters.”  What stage would she be in?

 As her CHW, you may want to show her charts of what normal weight ranges look like, and what weight loss could do for her health. Are there things that she can’t do now that she could do if she was at a lower weight?

Quiz Time  On your second meeting, Mrs. Apple tells you that her sisters are also in poor health, and she thinks it would be a good idea to lose some weight. But, she has many parties to attend in the upcoming months, and she thinks it would be difficult to not eat what is being served at the parties. But, as soon as the summer is over, she is ready to start a diet.  What stage would she be in?

 Maybe you can encourage her by practicing ways that she can say “no” to another helping of dessert, or letting others know that she is trying to watch her diet. Perhaps, you can help her with a checklist of things that will help her prepare for her weight loss goal.

Quiz Time  You meet with Mrs. Apple again in two months, and she is ready to start her new diet. She is excited that her friend also wants to lose some weight, and are ready to go on the first of the month.  What stage would she be in?

 You may want to talk about healthy diets and balancing meals. Perhaps, you can refer her to a nutritionist who can help her plan her new eating habits. Are there exercises that she likes to do, such as swimming or walking? Are there any programs in your community that can help her get an exercise routine in? Does she like to cook, and if so, are there some useful cookbooks you can loan her or have her purchase?

Quiz Time  You check in with Mrs. Apple in four weeks, and she is doing very well on her diet. She has already lost 7 pounds, and is taking a 30 minute walk with her dog every morning. She still likes to have a bowl of ice cream every night, but she doesn’t think that is a big deal.  What stage would she be in?

 Congratulate her on her new routine and weight loss. Perhaps, you can offer her healthier alternatives for ice cream, or encourage moderation. “Wow. You are doing great! Ice cream is delicious, and l like to have some too. Perhaps you can try having it every other night, or switching to low-fat yogurt?”

Quiz Time  When you meet with Mrs. Apple in six months to check-in with her, she has noticeably lost some weight. She tells you that she has lost 42 pounds over the last four months, and only eats a bowl of ice cream on Friday evenings. She has 20 more pounds to go to achieve her goal, but she has completely changed her eating habits and exercise routine—she now eats six small meals a day, and walks 45 minutes every morning. She says she is able to play hopscotch with her granddaughter now without tiring out too quickly. Her glucose levels are much better, and her doctor is excited for her.  What stage would she be in?

 Keep on congratulating her! What great news and such hard work for getting closer to her goal! Remind her that her new routine is what is important, and the weight loss is just a bonus. Are there any obstacles or challenges she faces, or is concerned with in the future, that would prevent her from continuing?

Quiz Time  Four weeks later, you receive a call from Mrs. Apple. She has gained five pounds and hasn’t walked in two weeks. She hurt her knee one day, and fell out of routine. She doesn’t see the point in continuing, if it is so easy to gain weight. But, she is ready to try again and wants to know if you could come by to take a walk with her.

 As her CHW, this may be a good opportunity to remind her that everyone slips up once in awhile and that is OK. Remind her of the positives, such as the other weight she lost and playing with her granddaughter. And if you are able and comfortable with the idea, head out as soon as you can to take a walk with her. It will give you some time to listen to Mrs. Apple vent a bit, and help her get back on track. Was hurting her knee the only problem, or were there other stressors involved?

Family Practice  Helping patients change behavior is an important role for family practice.  The concepts of “patient noncompliance” and motivation often focus on patient failure.  Understanding patient readiness to make change, appreciating barriers to change and helping patients anticipate relapse can improve patient satisfaction and lower physician (and staff) frustration during the change process.

William Miller Ph.D & Stephen Rollnick Ph.D  Motivational interviewing is non- judgmental, non-confrontational and non-adversarial.  The approach attempts to increase the patients awareness of the potential problems, consequences and risks associated with their behavior.

Motivational Interviewing (MI)  A process that helps the patient move through the stages of change

New Vision for the Future  We help patients envision a better future and become more motivated to achieve it.  MI seeks to help patients think differently about their behavior and ultimately to consider what might be gained through change

MI uses four general processes to achieve its ends:  Engaging - used to involve the client in talking about issues, concerns and hopes, and to establish a trusting relationship with a counselor.  Focusing - used to narrow the conversation to habits or patterns that clients want to change.  Evoking - used to elicit client motivation for change by increasing clients' sense of the importance of change, their confidence about change, and their readiness to change.  Planning - used to develop the practical steps clients want to use to implement the changes they desire.

Direct, Listen, or Guide?

 Open-ended Questions Vs.  Closed-ended Questions

Example of MI  rJJPCuTE

So What Does This Mean in Our Practice  The Stages of Change model is useful for selecting appropriate interventions.  By identifying where a patient is in the change process, we can tailor the intervention  The focus of the office visit is not to convince the patient to change behavior but to help the patient move along the stages of change.  Using the framework of the Stages of Change model, the goal for a single encounter is a shift from the grandiose (“Get patient to change unhealthy behavior.”) to the realistic (“Identify the stage of change and engage patient in a process to move to the next stage.”).

Practicing Motivational Interviewing  Ask where the person wants to go – get to know them a bit  Inform the person about options and see what makes sense to them.  Listen to and respect what the person wants and offer help accordingly.

Ambivalence  People feel ambivalent about change  I need to loose weight but I hate to exercise; I need to stop smoking, but I just can’t seem to do it; I want to get up but it hurts.  Most people want to be healthy AND are comfortable with familiar routines Pro’s Con’s

Change Talk  Listen for change talk  Desire: I wish I could ____  Ability: I could probably take a walk ___  Reasons: I want to be around for my kids  Need: I’ve got to get back some energy  Commitment: I will, I promise, I am ready to….

Change Talk  When you hear change talk you’re on the right track  If you find yourself arguing for change and the person defending the status quo you’re off course.

Practice Roll play scenario  One is the patient  One is the care provider  One is an observer Observers take notes and give feedback

Use this scenario  Patient expresses desire to stop smoking  He has tried before with some success – quit for 3 weeks  Motivated by family pressure and….  Wants your help GOAL Identify the stage of change and engage patient in a process to move to the next stage.