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Behaviour change theory and motivational interviewing

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Behaviour Change Theory

This session focuses on the principles of behaviour change theory and utilising tools to examine a client’s behaviour, readiness to change and support the changes they wish to implement.

Considering the idea of developing healthy behaviours, utilising the principles of behaviour change enable us to target the way that we work in order to be effective – for example, asking the right questions and providing the right type of support to make our intervention as effective as possible.

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Principles of Behaviour Change

Transtheoretical model of behaviour (stages of change) Prochaska & DiClemente (1984)

Outlined a new (in 1984) approach to assisting patients to make changes to their behaviour. It has been successfully applied in various health settings, in particular tackling alcohol, drug and smoking addiction. They summarised that people entered various different points when considering change/changing their behaviour. They outlined a model of change – described on the next slides.

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Stages of ChangeKey principles:• 5 stages:

• Precontemplation • Contemplation • Preparation• Action• Maintenance. • Relapse is an additional stage which can occur at any

point.

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Stages of Change

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Stages of Change• Pre-contemplation - Not intending to take action within

the next 6 months. Content with current behaviours.

Your role is to raise doubt/increase their perception of risks/problems with their current behaviour

• Contemplation – Thinking about change within next 6 months.

Your role is to raise with them reasons to change, the risks of not changing, strengthen their confidence to change and motivate their behaviour

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Stages of Change• Decision – resolved to make a change, preparation and

taking action within the next month.

Your role is to help them create a plan, discuss the risks of not changing, set a date and goals.

• Action – making specific modifications to behaviour.

Your role is to continue to ask questions about successes/difficulties but focussing on success. Be generous with praise and admiration. Develop practical methods of encouragement and support.

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Stages of Change• Maintenance – undertake different behaviours and

working to prevent relapse.

You role is to identify and use relapse prevention strategies, identifying any barriers or areas of weakness with client. Work on other lifestyle choices.

• Relapse - is an additional stage which can occur at any point in the process of change. Client returns to their prior state. Your role is to focus on where they are and focus on realistic goals to return them to making progress.

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Considering motivation to change

Review the Case Studies in Etivity 6.1.

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Supporting changeThere are a number of tools and worksheets available in the manual to support clients in making decisions, weighing up the benefits of making changes and helping them to plan against lapses and re-lapses.A client entering the service may be very clearly motivated and ready to change. Others may enter the service at the pre-contemplation or contemplation stage which will require work around looking at benefits of change in more detail. Following this slide we will showcase tools to assist you in doing that.

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Supporting changeBalance SheetsThese sheets help you to look at the behaviour a client needs to change – for example, eating healthily, being more active, stopping smoking and helps them to look at why this might be an advantage or disadvantage to them. In doing this, they have to consider the benefits of change which will often be more persuasive than the dis-benefits. The next slide will demonstrate a worked example.

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Supporting changeBalance SheetsArea of change: Eating healthily

Possible advantages:Lose weight, good for baby, feel better,maybe less heartburn,

Possible disadvantages:Expensive, I like chocolate, I don’t like vegetables, takes more effort to make healthy food.

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Supporting changeBalance Sheet 1

The client then needs to rate howcertain they are about changing.This would include a discussionwith you around the potential impact of change, exploring someof their disadvantages, for example, cost of healthy foods.

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Supporting changeBalance Sheet 2This sheet is useful if a client hasidentified more disadvantages tochanging their. It enables you to work through the disadvantagesand gets them to think about whatmight happen if they continue as they are. See the next slide for a worked example.

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Supporting changeBalance Sheet 2Disadvantages:ExpensiveI like chocolate I don’t like vegetables Takes more effort to make healthy food

Ways to reduce these:Expensive – show real life examples of cost, ask client what they eat now and compare a fresh cooked e.g.

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Supporting changeBalance Sheet 2I like chocolate – you can still eat andenjoy chocolate in moderation, particularly if you increase how muchactivity you do

I don’t like vegetables – which vegetables do you not like, have you tried all kinds. Do you like fruit?

Takes more effort to make healthy food – what foods would you normally prepare – how long would that take?

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Supporting changeBalance Sheet 2Takes more effort to make healthy food – what foods would you normallyprepare – how long would that take? What sort of things are you thinking about?

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Supporting changeBalance Sheet 2You then work through the advantages and disadvantages of not changing:

Advantages – stay the same, eat what I like, costs the same, know what to buy

Disadvantages – health risks, gain more weight, indigestion/heartburn, etcThen ask the client to consider the question about change again.

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Balancing benefits

Etivity

Consider the case study example and work through potential answers to the Balance

Sheet questions.

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Overcoming barriers and utilising facilitators

When working with clients who are seeking to change their behaviour – whether by focussing on diet or activity, or both – there are often barriers, whether perceived or real to implementing those changes. Barriers often threaten the client’s ability to change and need to be addressed as part of the work of the HWA. Examples follow.

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Overcoming barriers and utilising facilitators

Potential Barriers – things/people/places/feelings that are unhelpful to changing behaviour

• Time• Existing habits• Family/friends• Social situations• Eating out/eating at home• Equipment – exercise or cooking

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Overcoming barriers and utilising facilitators

Potential Facilitators – things/people/places/feelings that are helpful to changing behaviour/make it easier

• Who can support client?• How could shopping differently support choices?• What are the benefits of the new behaviour?

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Overcoming barriers and utilising facilitators

There are various tools that you can use with clients to discuss the potential barriers and to help them explore facilitators. A key element of their behaviour change will be around planning for success – if they can identify barriers, they can then work on plans around what to do to resolve those barriers. For example, if the woman’s husband is a barrier, how can she encourage him to support her. Why is he a barrier?

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Motivational InterviewingMotivational interviewing is based upon four general principles:• Express empathy - sharing with clients your understanding of their perspective• Develop discrepancy - helping clients appreciate the value of change by exploring the discrepancy between how they want their lives to be vs. how they currently are• Roll with resistance – you accept that it is natural for client’s to be resistant to change• Support self-efficacy – you embrace client autonomy (even when clients choose to not change) and help clients move toward change successfully and with confidence.

The main goals of motivational interviewing are to establish rapport, get them to move towards talking about making changes and establish commitment language from the client.

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Motivational InterviewingKey principles include:• motivation to change must come from the client themselves, not be directed by anyone else• it is the client’s task to resolve any ambivalence to change – the HWA’s role is to aid the client in exploring their feelings and guide them towards positive resolution• direct persuasion is not effective at helping clients change – in fact, it is likely to make them more resistant to making changes• the counselling style is usually a quiet, and eliciting one, encouraging the client to find solutions and explore their feelings•The relationship is more like a partnership than a client/therapist relationship

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Motivational InterviewingKey principles include:•Seeking to understand the person's frame of reference, particularly via reflective listening  •Expressing acceptance and affirmation  •Eliciting and selectively reinforcing the client's own self motivational statements expressions of problem recognition, concern, desire and intention to change, and ability to change  •Monitoring the client's degree of readiness to change, and ensuring that resistance is not generated by jumping ahead of the client.  •Affirming the client's freedom of choice and self-direction 

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Motivational InterviewingThe following attributes would be examples of behaviour contrary to the approach of motivational interviewing.The worker:• argues that the person has a problem and needs to change  • offers direct advice or prescribes solutions to the problem without the person's permission or without actively encouraging the person to make his or her own choices  • uses an authoritative/expert stance leaving the client in a passive role  •does most of the talking, or functions as a unidirectional information delivery system  • imposes a diagnostic label  • behaves in a punitive or coercive manner 

Further information can be seen at www.stephenrollnick.com

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Motivational Interviewing

Etivity

Case study review