The Magic Of Behavior Change Handout

Objectives
1. Explain how psychosocial models can
assist them in encouraging patient
behavior changes.
2. Define motivational interviewing.
3. Discuss techniques of motivational
interviewing

Health Behavior Change
• A strategy and collection of methods geared
to the brief patient-centered consultation,
based on:
 Motivational Interviewing
 Stages of change model
• It is:
 Patient-centered
 Directive
 A method of communication
 Used to explore and resolve ambivalence.

Rollnick S, et al. Health Behavior Change: A Guide For Practitioners. Churchill Livingstone; 2003:10,11.
Miller WR, et al. Motivational Interviewing. 2nd ed. Guilford Press; 2002:25.

Vision of this Learning Experience
• Evolution from the biomedical way of thinking
– “Traditional model”
– Tell patients what to do
– “Because I said so”
– “Yes, but you will end up with this problem____.”
• To the psychosocial model
– Empowerment where the HCP and patient are a team
– Promotion of patient involvement in their care
– Determining patient’s barriers and goal setting
– A paradigm shift for the provider of care

Biomedical Model
of Health and Illness
• Assumes the patient is or should be
sufficiently motivated by illness to obey
instructions
• Treatments are offered to patients who
are not ready to follow them
• Reflects bias toward treating the disease
and fails to address the behavioral
requirements of the treatment
• Interventions following this model are
unlikely to cause sustained changes in
compliance

WHO. Adherence to Long-Term Therapies: Evidence for Action. WHO; 2003:139.

Biomedical Behavioral
Practitioner centered Patient centered

Information giving Information exchange
“Save” the patient Patient “saves” self
Dictate behavior Negotiate behavior
Compliance Adherence
Authoritarian (P-C) Servant
Motivate the patient Assess motivation
Persuade, manipulate Understand, accept
Resistance is bad Resistance is information
Argue Confront
Respect expected Respect earned

Behavioral Model:
Information-Motivation-Behavior Skills Model

• Presence of both information and
motivation increase the likelihood of
adherence
• Interventions based on this model have
been effective in influencing behavioral
change in a variety of clinical applications
Information

Behavior Skills Behavior Change

Motivation
Source: Fisher JD, Fisher WA. Psychol Bull, 1992, 111:455–474; Fisher JD et al. Health Psychol, 1996, 15:114–123; Carey MP et al. J
Consult Clin Psychol, 1997, 65:531–541; Mazzuca SA. J Chronic Dis, 1982, 35:521–529. as quoted in WHO, 2003.

Evidence of Effectiveness
• Motivational Interviewing techniques have
been effective for treating alcohol and drug
problems, patients with diabetes,
hypertension, and bulimia
• The Motivational Interviewing process has
been found superior to no-treatment control
groups
• Readiness to change model was able to
predict clinical improvement in patients with
diabetes
Miller WR, et al. Motivational Interviewing. 2nd ed. Guilford Press; 2002:217-250.
Peterson KA, et al. Readiness to change and clinical success in a diabetes education program. J Am Board Fam Pract.
2002;15:266-271.

Stages of Change
(Transtheoretical) Model
• 5 stages of change
• Useful for selecting Precontemplation
appropriate interventions
• By identifying a patient's
position in the change Maintenance Contemplation
process, physicians can
tailor the intervention,
usually with skills they
already possess. Action Preparation
• The focus is not to convince
the patient to change
behavior but to help the
patient move along the
stages of change.

Source: Prochaska, Am Psychol 1992; 47:1102-4.

The Spirit of
• Collaborate with the patient

• Evoke their readiness to take
action

• Develop patient’s autonomy to
take responsibility for their own
health

Assessment

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• Factors to consider
– Age
– Cultural issues
– Language
– Co-morbidities
• Patient knowledge
– Health literacy Identify and
– Disease specific
• Medications prioritize the
• Complications patient’s
– Management of disease
process/lifestyle change barriers
• Patient’s motivation
– Change lifestyle
– Manage disease
– Support system

Numerous Barriers
• Depression/fear • Cost of care

• Fatalism/denial • Age/physical limitations

• Nonchalance • Cultural beliefs/traditions

• Perfectionism • Lack of social support

• Anxiety/
• Lack of understanding: Myths
frustration

Ambivalence
• Person’s desire to do nothing

• Can be a key issue that must be resolved
for change to occur

• Health Behavior Change process may help
people get unstuck from their
ambivalence


Resistance Can Be Bad or Good
• Resistance can disrupt and impact the rapport
between the patient and healthcare provider

• Resistance can be a sign of a patient’s internal
conflict between their current behavior and their
desired behavior

Rollnick S, et al. Health Behavior Change: A Guide For Practitioners. Churchill Livingstone; 2003:23-24.

Four Categories of
Resistance Behavior
• Negating
– blaming, disagreeing, excusing, minimizing,
claiming impunity, pessimism, reluctance,
unwillingness to change
• Arguing
– challenging, discounting, hostility
• Interrupting
• Ignoring
– Inactivity – patient does not fill prescription

Miller WR, et al. Motivational Interviewing. 2nd ed. Guilford Press; 2002:48

“YES, BUT…” and PERSUASIVE
COMMUNICATION

Are NOT the solution to resistance!

Understanding, exploration, and patience are the
solution!

Techniques
• Elicit-Provide-Elicit
– Menu of Strategies
• The Five Principles
– READS
• Helpful Tools
– Readiness Rulers
– The Envelope

Rollnick S, et al. Health Behavior Change: A Guide For Practitioners. Churchill Livingstone; 2003:109.
Berger B. Motivational interviewing helps patients confront change. Available at:
http://www.uspharmacist.com/oldformat.asp?url=newlook/files/Phar/nov99relationships.cfm&pub_id=8&article_id=450.
Accessed January 13, 2004.

The Menu of Strategies: Elicit
• Opening strategy: discussing patient’s
lifestyle, how does the patient view it?
• A typical day: what’s the routine?
– Needed for tailoring
– Identifying dietary needs/problems
– Exercise


• The good things and bad things
– What do they like and dislike about the proposed
changes?
– What is their representation of the illness and its
treatment?
– Do they agree with the MD?
– Do they believe they can do what is asked? What
will help?
– What are the barriers?
http://www.uspharmacist.com/oldformat.asp?
url=newlook/files/Phar/nov99relationships.cfm&pub_id=8&article_id=450. Accessed January 13, 2004.

Prioritizing Barriers
• Evaluate and Identify barriers, then….
• Prioritize
– Patient prioritizes barriers
– To assist, HCP may ask….
• What is the one thing that most keeps you from…”
• “Can you pick out a single problem that most hinders
your progress in…”
• “If I told you that you can live a long, healthy and
enjoyable life, and you were going to disagree with me,
what would you say?”
– Patient and HCP agree on a plan

Readiness Ruler
• Useful tool when you encounter
resistance
• Elicits change talk
• Evaluates two concepts
– Importance
– Confidence
• Scale from 1 to 10

Zimmerman GL, et al. A ‘stages of change’ approach to helping patients change behavior. Am Fam
Physician. 2000:61:1409-1416.

Readiness Ruler Questions
• “How important is this change for you?”
• “How confident are you that you can make this
change if you want to?”
• “Why did you choose a ____, not a 1?”
• “What would have to happen for it to be a _____?”
(next highest number from what they stated)

Zimmerman GL, et al. A ‘stages of change’ approach to helping patients change behavior. Am Fam
Physician. 2000:61:1409-1416.

Readiness Ruler:
Follow-up to Patient Response
• If the answer is 4 to 10, ask or say….
– Congratulations! What is helping you?
– What else can help?
– What are your high-risk situations?
• If the answer is 1-5, ask or say….
– Would you consider yourself to have “fallen off
the wagon”? If so, what worked for a while?
– Don’t kick yourself—long term change almost
always takes a few cycles.
– What did you learn from the experience that will
help you when you give it another try?

The Envelope
• Elicits change talk
• “If I handed you an envelope, what would
the message inside have to say to get you
to ________?”
• Useful when there is ambivalence

The Menu of Strategies: Provide
• Providing information — is the patient ready for
information?
• Provide patient with all appropriate information
– Dosing – how much to take and when to take it
– What the expected onset of action is
– Most common side effects and what to do if any occur
– What to do if there are problems
– Ask if patient has any further questions

Berger B. Motivational interviewing helps patients confront change. Available at: http://www.uspharmacist.com/oldformat.asp?


• The future and the present—
additional concerns
• Helping with decision making
– “What are your thoughts now about
managing your...”
– “Where does this leave you now?”
– “Do you anticipate having any help?”

• ELICIT PROVIDE ELICIT
Rollnick S, et al. Health Behavior Change: A Guide For Practitioners. Churchill Livingstone; 2003:112.

The Five General Principles of
• READS
• Roll with resistance
• Express empathy
• Avoid arguing
• Develop discrepancy
• Support self-efficacy


Principles of Health Behavior Change:
Roll With Resistance
• Use understanding, empathy
• Get clarification
• New perspectives are invited, not
imposed
• Don’t give person a reason to resist more
• Resistance is a signal to respond
differently
• Repeat your understanding
• The person is a primary resource in
finding answers and solutions

Express Empathy

• An objective identification of another
person’s emotions (not their
experience)
• Done throughout the process (menu)
• Identify and understand resistance,
reasons for unhealthy behaviors
without judgment
• Creates a climate for change through
trust

What is NOT Listening
• Ordering, directing, commanding
• Warning or threatening
• Giving advice, suggestions, solutions
• Persuading or lecturing
• Moralizing, preaching (fixing, healing, and
converting)
• Disagreeing, judging, criticizing, or blaming
• Agreeing, approving, or praising
• Shaming, ridiculing, or labeling
• Reassuring, sympathizing, or consoling
• Questioning or probing

Principles of Health Behavior
Change: Avoid Arguing
• Don’t add to the person’s resistance
• Arguing forces people to defend the
behavior you are trying to change
• Empathy sets you up as being on “their”
side
• Confront, but don’t argue
• Feelings aren’t arguable


Develop Discrepancy
• Discrepancy = Dissonance
• Good things and bad things about change
• Pros and cons
• Throw system out of kilter
• Restate the discrepancies heard
• Change is motivated by a perceived discrepancy
between present behavior and important personal
goals or values


Support Self-Efficacy
• A person’s belief in the possibility of change is an
important motivator
• Notice the positive, including statements, not
just behaviors
• Let the person know you’ve noticed
• The person, not the counselor, is responsible for
choosing and carrying out change
• Let them know how you feel
• Praise the behavior, not the person
• Continue to support self-efficacy throughout the
process

Health Behavior Change Summary

• Elicit - Provide - Elicit
• Address ambivalence, create dissonance
• Explore resistance
• Ask evocative questions
• Exploring the concerns and the pros and cons of
change
• Ask the patient to elaborate
• Elicit change talk
• Identify patient’s Goals and Values

The Magic Of Behavior Change Handout

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