“Practical strategies to institute behaviour change in your patients” Ilda Caeiro, B.A./B.S.W., M.S.W., R.S.W.

Objectives Self-Determination Theory-a paradigm for health care Motivational Interviewing and Supporting Research Defining Motivational Interviewing Using motivational interviewing to address resistance and readiness for chance

Before we begin… A fun little exercise…

So why is it so hard to change? Is it social, environmental, or internal influences? Michelangelo’s David after his stay in North America

Self-Determination Theory-A paradigm for Healthcare General Theory of behaviour for human beings-respecting, supporting, and facilitating autonomy in our patients BUT people do not have to listen to our recommendations and this is where motivational interviewing comes in to play…

Solutions do not always seem rational

Can we really motivate change? Case Study John is an 18year old young man with class three obesity Pre-contemplative phase He has come to the clinic with a weight loss goal of 100lbs John wants to do Optifast program He has been unsuccessful in managing his weight independently Hx of binge eating behaviours and consuming high levels of alcohol He’s a typical teenager…enjoys going out with friends, which typically consists of drinking and eating out What do you think is John’s motivation to lose weight at this time? Can he be motivated to make lifestyle changes? i.e. reduce drinking and partying with his friends and not eat out as often?

Patients do not always see the risks…

Motivation??? Motivation can be defined as human energy directed toward a particular goal It’s about free choice Assumptions: Humans are innately motivated toward well being and personal growth

Three Psychological Needs Supporting Optimal Motivation AUTONOMY COMPETENCE RELATEDNESS ***motivational Interviewing supports autonomy and relatedness*** AUTONOMY- the need to feel choiceful and volitional in ones behaviour COMPETENCE-the need to feel optimally challenged and capable of meeting outcomes RELATEDNESS-need to feel connected and understood by important others ***motivational Interviewing supports autonomy and relatedness***

Motivational Interviewing (MI) Ideal for patients in pre-contemplation and contemplation stages of change Goal is to assist patients move from pre-contemplation and contemplation stages into preparation and action stages ***see handout from American Medical Association for Assessment of Patient Readiness and Stages of Change***

Effectiveness of Motivational Interviewing (MI) within Health Care Studies examining the use of MI or MI in combination with other interventions provide evidence for the effectiveness of MI within health care Butler et al. 1999; 49: 611-6

MI has been effective in assisting patients: control glucose levels (Channon et al. 2003, 2007; Smith et al. 1997; Viner et all 2003; Smith et al. 2007) increase physical activity (Smith-West et al. 2007) decrease weight (Smith et al. 2007) engage in dietary changes (Brug et al. 2007, Clark & Hampson, 2001)

Motivational Interviewing in Health Promotion Smith West et al. (2007) Population- overweight women Subjects-217 Dose of MI-5, 45minutes sessions, one delivered before starting behavioural obesity treatment and then again at 3, 6, 9, 12months. Attrition rate-7% F/U- 6 and 18months Outcome-women in motivational interviewing lost significantly more weight at 6 months and 18months. Significant greater A1C reductions were observed in those undergoing motivational interviewing at 6months, but not at 18months

Bennet, Lyons, Winters-Stone, Nail and Scherer (2007) Population-Physically Inactive Adult Cancer Survivors Subjects- 56 Comparison Groups- Motivational Interviewing (28), Control (28) Dose of MI-one 30minute Session and two follow up telephone calls Attrition rate-14% F/u-3, 6months Outcome- a significant increase in physical activities was noted in the MI group compared to the control group

Carels et al. (2007) Subjects-55 Population-Obese Sedentary Adults Comparison Groups-behavioural weight loss program(27), behavioural weight loss with stepped care (28)of which 19 received MI Dose of MI-46-60min sessions provided to participants in the behavioural weight loss program with stepped care who failed to meet their weight loss goals Attrition Rates-16% F/U- 3, 6,12, 18 weeks Outcome-Participants who received MI lost significantly more weight and engaged in more physical activity than those who did not

Building MI into Clinical Practice Health care professionals are often concerned about the time it takes to integrate MI into clinical practice One study of primary care physicians found that MI took an average of 9.69 minutes Borelli et al. 2007

The effectiveness of MI as a patient-centered approach MI overlaps with patient-centered medicine in that both approaches involve patient acceptance, collaboration, open-ended questions, and listening skills.

Motivational Interviewing: A Review MI is a communication method, not a theory or a technique, which supports autonomy and relatedness for patients Definition: “Motivational interviewing is a directive, client-centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence” Stephen Rollnick, Ph.D., & William R. Miller, Ph.D. (1995) Originally used with addictions it is focused and goal-directed The examination and resolution of ambivalence is its central purpose, and the counselor is intentionally directive in pursuing this goal.

The Interviewing process Motivational interviewing is based on three key components: Collaboration (vs. Confrontation) Evocation (vs. Education) Autonomy (vs. Authority) COLLABORATION: The counsellor avoids an authoritarian one-up stance, instead communicating a partner-like relationship. It involves more exploration and support rather than persuasion or argument. The interviewer aims to create a positive interpersonal atmosphere that is conducive but not coercive to change. For example: the counselor may validate or sympathize with a patient’s perceived challenges to incorporating physical activity to their daily routine, as opposed to confronting patient with making excuses EVOCATION: The interviewers tone is not one of imparting things, but rather eliciting, of finding these things within and drawing them out from the individual. It requires finding intrinsic motivation for change within the person and evoking it. For example: instead of providing the patient with education on the benefits to weight loss (which they probably already know), the focus would be to elicit the patients own reasons and perceived benefits to making lifestyle changes. AUTONOMY: responsibility for change is left with the client- the client is always free to take counsel or not. Again, the overall goal is to increase intrinsic motivation, so that change arises from within rather than being imposed from without and so that change serves the person’s own goals and values. It is the client who presents the arguments for change. For example: engaging the client in setting the agenda items for the meeting AND having the client set their own goals. The counsellor’s role at this point would be to assist the client in ensuring that goals are S.M.A.R.T. (specific, measurable, attainable, realistic, and time centered)*****

The spirit of motivational interviewing Motivation to change is elicited from the client, and not imposed from without It is the client's task, not the counsellor's, to articulate and resolve his or her ambivalence Direct persuasion is not an effective method for resolving ambivalence Motivation to change is elicited from the client, and not imposed from without. Other motivational approaches have emphasized coercion, persuasion, constructive confrontation, and the use of external contingencies (e.g., the threatened loss of job or family). Such strategies may have their place in evoking change, but they are quite different in spirit from motivational interviewing which relies upon identifying and mobilizing the client's intrinsic values and goals to stimulate behaviour change. It is the client's task, not the counsellor's, to articulate and resolve his or her ambivalence. Ambivalence takes the form of a conflict between two courses of action (e.g., indulgence versus restraint), each of which has perceived benefits and costs associated with it. Many clients have never had the opportunity of expressing the often confusing, contradictory and uniquely personal elements of this conflict, for example, "If I stop smoking I will feel better about myself, but I may also put on weight, which will make me feel unhappy and unattractive." The counsellor's task is to facilitate expression of both sides of the ambivalence impasse, and guide the client toward an acceptable resolution that triggers change. Direct persuasion is not an effective method for resolving ambivalence. It is tempting to try to be "helpful" by persuading the client of the urgency of the problem about the benefits of change. It is fairly clear, however, that these tactics generally increase client resistance and diminish the probability of change (Miller, Benefield and Tonigan, 1993, Miller and Rollnick, 1991). (patients may feel defiant towards the counsellor if they feel they are being told what to do)

Direct Persuasion-Does it Work?

The counselling style is generally a quiet and eliciting one The counsellor is directive in helping the client to examine and resolve ambivalence Readiness to change is not a client trait, but a fluctuating product of interpersonal interaction The therapeutic relationship is more like a partnership or companionship than expert/recipient roles The counselling style is generally a quiet and eliciting one. Direct persuasion, aggressive confrontation, and argumentation are the conceptual opposite of motivational interviewing and are explicitly proscribed in this approach. To a counsellor accustomed to confronting and giving advice, motivational interviewing can appear to be a hopelessly slow and passive process. The proof is in the outcome. More aggressive strategies, sometimes guided by a desire to "confront client denial," easily slip into pushing clients to make changes for which they are not ready. The counsellor is directive in helping the client to examine and resolve ambivalence. Motivational interviewing involves no training of clients in behavioural coping skills, although the two approaches not incompatible. The operational assumption in motivational interviewing is that ambivalence or lack of resolve is the principal obstacle to be overcome in triggering change. Once that has been accomplished, there may or may not be a need for further intervention such as skill training. The specific strategies of motivational interviewing are designed to elicit, clarify, and resolve ambivalence in a client-centred and respectful counselling atmosphere. Readiness to change is not a client trait, but a fluctuating product of interpersonal interaction. The therapist is therefore highly attentive and responsive to the client's motivational signs. Resistance and "denial" are seen not as client traits, but as feedback regarding therapist behaviour. Client resistance is often a signal that the counsellor is assuming greater readiness to change than is the case, and it is a cue that the therapist needs to modify motivational strategies. The therapeutic relationship is more like a partnership or companionship than expert/recipient roles. The therapist respects the client's autonomy and freedom of choice (and consequences) regarding his or her own behaviour.

Back to John Typically change ONLY occurs when humans believe that the cost of NOT changing is HIGHER than maintaining the status quo So for John, change would only occur if the rewards of change were HIGHER than drinking and partying with his friends

Update on John After engaging John in MI and identifying his true motivation for change, John engaged in significant lifestyle changes He stopped drinking Would ‘hang out with friends’ but not eat out Journal food, mood and activity Engaged in regular exercise Addressed roots of emotional eating Results John lost 25lbs in four weeks and has continued to lose weight He reports higher self esteem and self confidence What was John’s Motivation???

Role of the Practitioner: Four Principles of MI Express empathy Develop discrepancy****** Roll with resistance –avoid argumentation Support self-efficacy Express empathy: Refers to the practitioner making a genuine effort to understand the client’s perspective and an equally genuine effort to convey that understanding to the client. This is an inherent element of reflective listening. It embodies the spirit of MI. Rogers (1962) “…as I see it is that the counselor is experiencing an accurate empathic understanding of his client’s private world, and is able to communicate some of the significant fragments of that understanding.” “When the client’s world is clear to the counselor…he can also voice meanings in the client’s experience of which the client is scarcely aware…” He referred to this “highly sensitive” empathy as important for making it possible for a person to get close to himself and to learn, to change and develop. Develop discrepancy: This is to listen for or employ strategies that facilitate the client’s identification of discrepant elements of a particular behavior or situation. Example, values versus behaviors: It is important to the client to be a responsible parent; but the client is having difficulty averting from binge eating. Discrepancy may result in the client’s experience of ambivalence. Areas of discrepancy may include: past versus present; behaviors versus goals. Evoking change talk is one way to develop discrepancy. (clients at our clinic often speak of wanting to be good examples for their children, who are often also over weight, but they struggle with refraining from eating high fat diets and leading sedentary lives) Roll with resistance –avoid argumentation: This refers to the provider’s ability to side step or diminish resistance and proceed to connect with the client and move in the same direction. It also refers to avoiding arguments. Expressing empathy, understanding why a client has a particular belief might be the intervention. Shifting focus might be another. Support self-efficacy: This is the provider’s ability to support the client’s hopefulness that change or improvement is possible. Identifying and building upon a client’s strengths, previous successes, efforts and concerns. These are some areas that may open the process of addressing and supporting the client’s hope and confidence.

Where to begin… A good place to start is by letting the patient set the agenda for the meeting. “As you know there are a number of things that we could discuss today-such as monitoring your blood pressure levels, healthy diet, exercise, and your medication-but what are you most concerned about? What would you like to talk about today? Perhaps there are other things that you feel are more important to discuss”

Five Strategies used throughout Motivational Interviewing: Open ended questions Affirm Reflective listening Summarizing Elicit Change Talk – self motivational statements Open ended questions: Open ended questions facilitate a client’s response to questions from his or her own perspective and from the area(s) that are deemed important or relevant. This provides the opportunity for clients to express their point of view, and for counselors to discover and follow the client’s perspective. This is in contrast to closed questions that are leading; they target specific information and give the client very little room to move. Example open question: “What makes you think you should make a change?” (Following). Example closed question: “Don’t you think you consume too much?” (Leading). Another distinction between open and closed questions is that open questions elicit fuller responses where closed questions can often be given a yes or no response. Affirm: Affirming means to actively listen for the client’s strengths, values, aspirations and positive qualities and to reflect those to the client in an affirming manner. Example: client discusses many previous efforts to change a particular behavior from the position of feeling like a failure or hopelessness. Counselor reframes (from a negative to positive perspective) and affirms. “What I am hearing is that it is very important to you to change this behavior. You have made numerous efforts over a long period of time. It seems that you have not found the way that works for you.” This reframe accomplishes both affirming the client for his or her efforts and perseverance and provides a framework for the client and counselor that entails finding a solution that will work for the client. This is in keeping with collaborative change plans that are used in motivational interviewing.  Reflective listening: Reflective listening entails a skillful manner of responding to what a client says. In MI the counsellor responds to clients with more reflective statements than questions. Reflections vary in complexity from simply repeating, to reflecting implicit meaning or reflecting feelings. The counselor follows the client’s ideas, perceptions and feelings making every effort to convey understanding; the client explores, defines or discovers what the behavior or lack of action may be about. Rogers noted that if the client perceives the counselor as “trying” he may be inclined to communicate more of himself. Reflective listening facilitates the client’s focus on his or her knowledge and resources. Reflections are always collaborative and non-judgmental. By many accounts when practiced skillfully reflective listening is a powerful and empowering response.  Summarizing: Summarizing is an important element of MI methodology. Sessions are ended with a strategic, collaborative summary. Interim summaries are used throughout the session. Summarizing includes directive elements. The provider may reinforce the client’s change talk; or highlight realizations; or identify transitions or progress (affirm); or identify themes. An interim summary has additional applications such as reviewing the direction of the session or changing focus; slowing down and addressing client’ statements; or clarifying what has been discussed so far. Elicit Change Talk – self motivational statements: In addition to responding to change talk that is offered by the client the provider uses strategies that elicit change talk. Some examples: *Evocative open questions - here the practitioner asks open questions that are targeted to change talk areas. Examples: “In what ways does this concern you” or “What do you see as a problem?” If the client responds, change talk has been elicited. *Looking ahead can be a written exercise or a verbal dialogue. “What might your life look like in five (1, 2, 3) years if very little changes?” What might your life look like in five years if a good deal of change takes place?” Responses to these questions may include client change talk. Example: “If very little change takes place I’ll probably get sicker and end up in hospital or worse, die.” Negative consequences. “If a good deal of change takes place I will no longer be limited physically, my health will improve, I will have more energy to spend playing with my children and will feel better about my self. I will also have a better possibility of watching my children grow up” Benefits of change.

Methods for Evoking Change Talk Using the Importance Ruler 0 1 2 3 4 5 6 7 8 9 10 Not at all Extremely Important Important

Readiness Ruler How important is it to start using some of these strategies/tools? How confident are you that you could apply them in your practice? How ready are you to actually use them?

Ruler Questions “How important would you say it is for you to lose weight? On a scale from 0-10, where 0 is not at all important and 10 being the most important thing at this time, where would you say you are?” “and how confident would you say you are, that if you decided to lose weight, you could do it” 0 is not at all confident and 10 is extremely confident, where would you be?”

“Why are you at an ____ and not zero?” “What would it take for you to go from ___ to (a higher #)” The method is to obtain the patient’s rating of importance and then ask… “Why are you a …. And not zero?” “What would it take for you to go from ____ to (a higher #)? By asking these type of questions you engage the patient/client on discussing what changes they are able to make and what they are doing right, as opposed to what they are not doing. This will engage the patient in a solution focused discussion on how to attain goals and what it will entail.

Methods for evoking change talk continued… 2) Exploring the decisional balance Advantages Disadvantages Maintaining Current Weight Losing Weight 2) Exploring the decisional balance- (discussing ambivalence and the weight matrix) 3) Elaborating

Methods for evoking change talk continued… 3) Elaborating 4) Querying Extremes 5) Looking Back 6) Looking Forward 7) Exploring Goals and Values 3) Elaborating Used by asking for clarification i.e. in what ways? How much? When? Asking for specific examples C) Asking for a description of the last time i.e. they attempted weight loss 4) Querying Extremes- When there seems to be little desire to change the present, another way to elicit change talk is to ask people to describe the extremes of their concerns, to imagine the extreme of consequences that might ensue. “What concerns you the most about your blood pressure in the long run?” “Suppose you continue on as you have been, without changing. What do you imagine are the worst things that might happen to you?” “How much do you know about what can happen if you continue to gain weight even if you don’t see this happening?” At the other extreme it can be useful to imagine the best consequences that could follow from pursuing a change: “What might be the best results you could imagine if you make this change” “If you were completely successful in making the changes you want how would things be different” 5)Looking Back- getting the client to remember before the problem emerged and to compare these times with their present situation “Do you remember a time when you felt in good health/weight?” “What changed?” 6) Looking Forward- helping people to envision a changed future “If you do decide to make a change, what do you hope might be different in the future?” “How would you like things to turn out for you 10years from now?” 7) Exploring Goals and Values

Evocative Questions Evocative questions ask the client directly for change talk… “in what ways does this concern you” “How would things be better if you changed” Evocative questions ask for commitment “so given all this, what do you think you will do next?” “what’s your next step”  Engagement - Building rapport: The MI practitioner begins by developing trust, building rapport, by following the client with empathic reflective listening. Expressing empathy, respect for autonomy, collaboration, genuineness -MI spirit is essential to the engagement process. One creates an atmosphere of safety and acceptance. The practitioner is careful not to prematurely address topics that may result in client-provider dissonance.  Goal Directed refers to identified target behaviors, goals and objectives. The counselor attains clarity about the target behavior or goal being addressed and works toward keeping the discussion focused on it. One may shift away from the topic if the client is expressing resistance or does not want to continue in this area. An example of a goal directed discussion is as follows: The client discusses historic or developmental issues that may be disturbing or painful. Once this discussion is completed the counselor will facilitate discussion of the relationship between the client’s historic developmental experiences and the client’s present goals. ((within our patient population our patients often disclose experiences of childhood sexual abuse and within these discussions, will speak of their relationship with food (which has often been used as a coping mechanism). Being able to discuss how their history may impact their goals is an important one))  Resolving ambivalence refers to facilitating the client’s exploration of ambivalence in a thorough manner, with the emphasis on change talk and tipping the balance towards behavior change. In effect, guiding the client to intrinsic recognition of whether or not the behavior is a problem and towards reaching a decision about change.  Menu of options: refers to a number of actions that a client and provider collaboratively identify and agree to include in a behavior change plan. Menu specifically refers to the identification of at least several (six, seven, etc.) actions versus one or two. Emphasis is placed upon the client’s willingness to pursue an identified action. Only actions that a client wants to pursue are included in a plan. The plan is fluid and can be changed. This menu and flexibility are noted to be directed toward confidence building (each action is prioritized via potential for success) and to convey hope that change can be attained. (utilizing MI, patients typically disclosed throughout the session behaviours which they identify as problematic i.e. drinking too much soda, not walking enough, eating big portions, or eating out 3-4times per week…these self-identified ‘problematic behaviours’ can then be summarized by the counsellor and used to assist the patient in developing goals.)  Pros and Cons refers to a strategic intervention that facilitates the exploration of the positive and negative experiences a client may have regarding a particular behavior. It also serves to elicit change talk when a client may not have identified any disadvantages voluntarily. One begins with an exploration of the positive experiences the client may have –sustain talk; reaches a level of comfort in this discussion; and then moves on to what is “not so good” about the behavior. A client who is comfortable may begin to identify some elements of concern either for the first time or in a way that is not resistant or guarded.  The decision balance This technique is not to be confused with MI itself. It has been noted that it is used routinely by some MI practitioners as a required technique (Miller & Rollnick, 2009). It is a form of identifying pros and cons within four quadrants. A. What is good about continuing the behavior; C. What is not good about changing the behavior; B. What is not good about continuing the behavior; D. What is good about changing the behavior. Weight is given to Columns A+B (what is good about continuing the behaviour and what is not good about continuing the behaviour)  Ask permission to give advice or information: In contrast to giving direct advice –“you should always eat breakfast and don’t snack late at night” A MI practitioner asks permission first. “Would you be interested in hearing my ideas about what might be useful?” If the client says yes, the practitioner might make suggestions. One also provides an opportunity for the client to reject the suggestions. “How do you think this might work for you?” The client pursues action only in areas agreed upon. Also, ask permission to provide education. “Would you be interested in learning more about this particular program” If yes, some written materials might be provided. Discussion and feedback would follow.

Looking Back… Looking Forward… Can you remember a time when you were pain free and active or eating was not a problem and you felt good about yourself? What was that time like? Think about what kind of a future you want to see for yourself?

Exploring Goals How does the behaviour fit with the patient’s values and goals? “What things do you regard as most important? How does this …fit?” “What sort of person do you want to be?” “What sorts of things would you like to accomplish in your life”?

How Change Fits Together Desire Ability Commitment Behavioural Change Reasons Taking Steps Need

DARN “Why do you want to lose weight [Desire]? How would you do it, if you decided to [Ability]? What, for you, are the three best reasons for losing weight [Reasons]? How important is it for you to lose weight [Need]?

Negotiating a Change Plan The development of this plan is a process of shared decision making and negotiation that involves: Setting goals Considering change options Arriving at a plan Eliciting commitment Setting goals-Key questions in this regard may be as follows: How would you like for things to be different? What is it that you want to change? Let’s take things one step at a time. What do you think is the first step? b) Considering change options- Once the persons relevant goals have been clarified, the next step is to consider possible methods for achieving the chosen goal “Here is a variety of possibilities that people have used successfully. Which of these do you prefer? Which do you think might work best for you?” ****HERE THE PATIENTS TASK BECOMES ONE OF CHOOSING, RATHER THAN REFUTING**** c) Arriving at a plan- This discussion leads directly towards the negotiation of a plan for change. As much as possible, elicit this plan by having the person voice it. KEY QUESTIONS: “SO WHAT IS IT SPECIFICALLY THAT YOU PLAN TO DO?” “ WHAT DO YOU THINK IS THE FIRST STEP?” “HOW WILL YOU GO ABOUT IT” D) Eliciting commitment

Change Questions… How would you like for things to be different? What is it that you want to change? Let’s take things one step at a time. What do you think is the first step? “Here is a variety of possibilities that people have used successfully. Which of these do you prefer? Which do you think might work best for you?”

Change Plan Worksheet The changes I want to make are… The most important reasons why I want to make these changes are… The steps I plan to take in changing are… The ways other people can help me are… I will know that my plan is working if… Some things that could interfere with my plan are…

Case Study 30year old female in class III obesity Married, with one young child Works part time outside of the home Physician referral with concerns pertaining to readiness/motivation Full psycho-social completed Patient presenting with ambivalence re: weight loss Initiated MI Patient disclosed childhood trauma and the use of food to heal Described food as an only friend and found it difficult to diet due to feelings of deprivation Felt she did not have time to exercise, eat healthy etc.

Where she is today… Prior to engaging in formal Opti-fast program patient lost a total of 30lbs. With just three MI sessions Since commencing LCD, patient has lost over 100lbs Patient reports feeling in control of life and decisions Experienced increase in internal motivation Reports increase in assertiveness skills, self esteem, and body image as well as improvements in her inter-personal relationships.

TAKE HOME MESSAGE Ask where the person wants to go and get to know him/her Inform the person about options and see what makes sense to them Listen to and respect what the person wants to do and offer help accordingly