1. Motivational Interviewing for Health Behavior Change Anita R. Webb, PhD JPS Health Network Fort Worth, Texas

2. GOALS Promote healthy behavior change in patients Improve patients’ current health status Prevent future health problems Strengthen physician-patient relationship

3. OBJECTIVES Learn how to use the “Stages of Change” model to help your patients improve health Decrease your frustration level in trying to “convince” patients to change Increase your satisfaction in working with patients

4. Key Points Changing our behavior is difficult. Convincing another person to change is even more difficult. Change occurs in predictable stages. Tools, planning and support can help. The process is slow. Relapse is the norm.

5. The Process When was the last time you tried to change your behavior? What was the behavior? Were you successful in changing? –For how long? –How many relapses?

6. The Process (continued) On average, how long does it take to “permanently” change a behavior? –Seven years People go through multiple stages in the process of change. –Why? What is the main barrier to change?

7. Ambivalence The main barrier to change is ambivalence. Demanding that another person change may actually delay that change. –Why/How? If you can’t “tell” a patient to change, what can you do to improve health behaviors?

8. Traditional Approach Giving Advice Success rates? –6-10% Drawbacks? –Makes people defensive –They are offended. Then what happens? –They resist your pressure to change. –Does not strengthen your relationship

9. Patient-Centered Approach No demands, no unsolicited advice So what CAN you do? –“Gentle nudging” in a supportive relationship Partnership: “Dancing, not wrestling” Promotes patient autonomy –Encourages decision-making Well-supported by research –But not for every patient?

10. ATTITUDE Patient centered interviewing is more an attitude than a method. –Respect, trust, accept –Build rapport –Enjoy the relationship Tools are offered if you want to use them.

11. YOUR ROLE 1. Listen, listen, listen –Understand patient’s agenda 2. Be aware of your own agenda –Surrender the need to control 3. Share the decision making –And the responsibility

12. Change Theory: Seven Stages 1. Pre-contemplation 2. Contemplation 3. Determination/preparation 4. Action 5. Maintenance [original model ends here] 6. Relapse 7. Termination

13. 1. Pre-contemplation The patient’s status –Not considering change –Denial: minimizes problem –Defensive: resists talk of unhealthy behavior Your goal: establish rapport –Encourage patient to talk about life goals. –Ask: “What’s important to you in your life?” –Ask permission to raise the issue in the future.

14. 2. Contemplation Patient’s status –Ambivalent about changing behavior –Willing to talk about it Your strategy and tools –Create discrepancy: “life goals” vs. behavior –Tool: “Pros and cons” of targeted behavior –Elicit self-motivational talk

15. Two Tools: Importance and Confidence Scales Ask the patient: 1. How important is it to you to change this behavior? 2. How confident are you that you will be able to change this behavior? These 2 tools can be used and re-used at any stage (and re-worded) as needed.

16. 3. Determination/Preparation Patient’s status: –Has made the decision to change –Sets a start date –Is considering methods and obstacles Your strategy/tools: –Ask permission to provide information –Strengthen the patient’s commitment –Provide a menu of change options –Express confidence in the patient

17. 4. ACTION Patient’s status –Implements new plan –Vulnerable to setbacks –May need extra support Your strategy/tools: –Identify new barriers –Offer menu of self-reinforcing options –Directly reinforce, support

18. 5. MAINTENANCE Patient’s status –Has achieved success –May have “slips” –Make plans to address obstacles/slips Your strategy/ tools: –Check status at each visit –Normalize slips –Express confidence in the patient –Recognize potential for relapse

19. 6. RELAPSE Patient’s status –Slips beyond “slips” –Reverts to “old ways” –Tempted to give up Your strategy/ tools: –Acknowledge relapse as norm –Re-establish their commitment and confidence –Suggest new change strategies –Express confidence in the patient

20. 7. TERMINATION Patient’s status: –Change is well-established Your strategy/ tools: –Reinforce accomplishment at future visits –By reminiscing with patient

21. Your Role at Each Stage 1. Precontemplation: Friend 2. Contemplation: Socratic teacher 3. Preparation: Consultant 4. Action: Coach 5. Maintenance: Consultant 6. Relapse: Coach 7. Termination: Friend

22. Your Goal Help patient move forward –Along the natural continuum of change Patient-centered approach –Collaboration, partnership –Respect their decisions, choices –Promote self-motivation/efficacy Your assets: Listening, empathy, rapport –Roll with resistance –Don’t take it personally!

23. Recommendations Relax about demanding that your patients change their unhealthy behaviors. Look for opportunities to nudge patients along the behavior change continuum. Support your patients’ rights to make their own choices –About their health –About their lives

24. “Brief Negotiation” Model System-wide training at Kaiser Permanente –Since 1992, Voluntary, Good results –Runkle C, Osterholm A, Hoban R, McAdam E, Tull R. Brief negotiation program for promoting behavior change: the Kaiser Permanente approach to continuing professional development. Education for Health 2000; 3(3): 377-386. Four principles are emphasized: –1. Stages of change –2. Danger of resistance –3. Encourage patient to talk –4. Express confidence in patient

25. Summary: Key Points Changing our behavior is difficult. Convincing another person to change is even more difficult. Change occurs in predictable stages. Tools, planning, and support can help. The process is slow. Relapse is the norm.

26. Final Reminder “Clinicians can’t change their patients’ behavior” “Only patients can.” Prochaska JO, DiClemente CC. Transtheoretical therapy: Toward a more integrative model of change. Psychother Theory Res Pract 1982; 19:276-288.