1. CHANGING BEHAVIOR CHERYL B. ASPY, PH.D. Motivational Interviewing

2. OBJECTIVES At the conclusion of this presentation, participants will be able to: 1.Apply the concepts of readiness for change and decisional balance with patients. 2.Demonstrate a 3-step process to encourage change. 3.Relate the concepts of Motivators and Self-Efficacy to behavior change. 4.Apply appropriate question-asking.

3. WHAT IS READINESS TO CHANGE?  A state of mind that guides decision- making  Recognizes that contemplation and planning come before reasoned action  5 specific stages of progression  Precontemplation  Contemplation  Preparation  Action  Maintenance ProgressProgress RelapseRelapse

4. WHY IS ENCOURAGING CHANGE (EC) AN IMPORTANT PART OF YOUR STRATEGY?  All behavioral change requires sufficient motivation to overcome the inertia of the status quo.  A systematic strategy can help you facilitate an individual’s readiness and commitment to change.  It consists of specific skills that can be learned and applied in many settings.

5. WHY IS EC AN IMPORTANT PART OF YOUR STRATEGY? (CONT’D)  If someone is not ready to change, he/she will resist all prescribed action plans and assigned tasks.  When the outcome supported by the change process is important to individuals and they have the confidence to achieve it, they are more likely to succeed in making the change.

6. WHY IS EC AN IMPORTANT PART OF YOUR STRATEGY? (CONT’D)  Telling someone to change their behavior when they don’t consider it important is unlikely to effect change.  Advice-giving is necessary but insufficient to change an individual’s behavior.

7. WHAT IS DECISIONAL BALANCE?  Every decision is made based on perceived gain.  For every decision there are advantages (pros) and disadvantages (cons).  When the pros outweigh the cons, a positive decision results and an action step can be taken.

8. AN ENCOURAGING CHANGE STRATEGY:  Creates a supportive environment in which patients feel they WANT TO and CAN CHANGE;  Explores patient’s ideas and concerns in a realistic manner; &  Research supports its efficacy in creating and sustaining change.

9. 3 PHASES  Quick assessment  Importance of the change  Confidence in ability to change  Patient identifies problems and solutions  Target and follow up

10. QUICK ASSESSMENT  On a scale of 1 to 10 with 1 being the lowest and 10 being the highest,  How important is it to you to make this change?  On a scale of 1 to 10 with 1 being the lowest and 10 being the highest,  How confident are you that you can make this change?

11. PATIENT IDENTIFIES PROBLEMS & SOLUTIONS  Physician Facilitation:  Question: Why are you at a 2 and not a 1? What would help you get to a 3?  Summarize pros and cons from patient perspective  Explore resistance  Discuss barriers and motivators  Brainstorm solutions

12. RESISTANCE APPROACHES 1.Roll with resistance – avoid argument 2.Emphasize personal choice and control 3.Reassess readiness, importance, and confidence 4.Don’t meet force with force – back off – use reflective listening – rephrase

13. TARGET & FOLLOW-UP  Patient should set a manageable goal.  Find out how you can best help.

14. STRATEGIES See Handout See Handout

15. ASK  ASK permission to address weight and its impact on health  Recognize that this must be done sensitively - obese people know they are overweight, they don’t necessarily appreciate having it pointed out.  How do you feel about your weight?  Is your weight a health concern for you?

16. ADVISE  Identify the physical dimension you believe the patient should consider changing and recommend it with conviction.  Example, “I’m concerned about your BMI because it is contributing to the complications related to your diabetes.”

17. ASSESS ASSESS readiness to make a change. ASSESS readiness to make a change. Consider IMPORTANCE (On a scale of 1 to 10 how important is to you to make a change?) Consider IMPORTANCE (On a scale of 1 to 10 how important is to you to make a change?) Consider CONFIDENCE (Use 1 to 10 scale) Consider CONFIDENCE (Use 1 to 10 scale) Identify motivators and barriers. Identify motivators and barriers. Discuss any resistance to change and start the process at a level with which the individual is comfortable. Discuss any resistance to change and start the process at a level with which the individual is comfortable.

18. ASSIST  ASSIST the patient in setting reasonable goals and adopting a feasible plan by providing information and an intervention.

19. ARRANGE  Schedule the patient for a timely follow- up and/or a referral to outside resources to insure continuous progress toward the goal.

20. CAUTIONS!  Build rapport and use active listening and empathic skills.  Work on one behavior or strategy at a time.  Be aware of your assumptions and check them out with the patient.  Keep it simple

22. SUMMARY  Ask about the behavior/goal  Assess Readiness for Change using  Importance (1 – 10)  Confidence (1 – 10)  Agree on the behavior change  Assist by developing motivators and helping to overcome barriers and resistance  Arrange follow-up to continue readiness development