Facilitating Change Motivational Interviewing

Setting Goals for Change

• Ideally, the goal must be the patient’s goal, unless the goals are in the ‘Best Interest” of the patient.

• Break the goal down into manageable chunks.

• If the person feels they have failed to achieve a goal, review it, modify the goal (simplify it, put supportive strategies in place) and try again.

Managing emotions

Return to work

Resuming roles

Social activities

Lifestyle

Mobility

Goals

Facilitating Behaviour Change & Motivational Interviewing

Cycle of Change (Prochaske & DiClemente, 1982)

Individuals have very basic motivations, and more complex ones.Motivation is not a personality trait or a static, stable entity (as in

“she is a very motivated person”) but rather acknowledges that we all have motivation

Stages of Change• Pre – Contemplation - The person is not

feeling ready to change, or even really thinking about it.

• Contemplation - The person may start to become more and more aware of the potential benefits of making a change.

• Preparation - At this point, the person has decided that they definitely do want to make a change, and start to make plans for how they can overcome barriers to change.

• Action - The person is making active attempts to change.

• Maintenance - The person may gain confidence as they see themselves making progress and become assured that they will be able to change.

• Relapse - The person loses all intention to carry on with the changes they are trying to make.

Motivational Interviewing• Once the importance of change

has been explored, and if it is felt that changing is important, then confidence can be brought into the equation.

• There needs to be a high level of both importance and confidence for change to occur.

• On a scale of 1-10, how important is it for you to change right now?1 2 3 4 5 6 7 8 9 10

• On a scale of 1-10, how confident do you feel that you could change?1 2 3 4 5 6 7 8 9 10

Behaviour Change

Confidence

Importance

Resistance to Change

• If you feel that a person is being resistant to change, you need to change your tack.

How resistance is communicated:Body language e.g. avoiding eye contact, folded arms.Presenting reasons for not changing (e.g. Yes, but)Making excuses for not changing.Disputing or directly challenging you, your information, and your competence.Arguing, interrupting, ignoring or denying

Overcoming Roadblocks and Resistance

Stage Technique/StrategyPre-Contemplation Roll with Resistance

Develop Discrepancy

Contemplation Affirming Provide personally relevant informationScaling questionsPros and cons listRoll with resistanceExplore barriersDecisional balance sheet

Determination/Preparation

Affirming Action plan – motivation list, problem solving, final barriers

Action Praise, support, reinforcementAmendments to action plan

Maintenance Reinforcement and rewardsPre-empt slips /relapse prevention

Praise emphasis on gains

Overcoming Roadblocks and Resistance

• Roll with Resistance - Avoid confrontation and try to get the person you are working with to recognise that they need/want to change themselves (rather than being told).

Rolling with Resistance Approaches:

Avoid Arguing - avoid having a direct, head-on argument with an individual as this is likely to make them feel defensive.

Listen - By showing that you have heard what they are saying, you may prevent them from instinctually being defensive

Encourage - encourage the individual to come up with their own suggestions for ways of changing their behaviour

Reflect - By doing it in a non-judgmental way, they will be assured that you are simply trying to understand them, rather than contradict them or express your own views.

Alternative viewpoints - By doing this, you are getting them to look at the other side of the argument but without directly challenging their views or passing judgment on their choices.

Overcoming Roadblocks and Resistance

• Develop Discrepancy - The aim of this strategy is to show a person that there is a discrepancy between their current behaviour and their desired or ideal behaviour.

• Affirmation - Affirmations are statements that acknowledge and recognise the positive steps that a patient has made in the direction of change.

• Provide Personally Relevant Information - The things that make people really want to change are the things that are personally relevant to them.

Overcoming Roadblocks and Resistance

• Scaling Questions - Scaling questions can be really helpful as they often allow you to break up the whole process of change into smaller chunks, making it less daunting for patients.

• Pro’s and Con’s List - It can be hard to see the big picture but when it’s all written down in front of you, you can really begin to see how many benefits there could be to changing.

• Explore Barriers - It is also important that you explore the barriers that are preventing change or making change more difficult., and validate these so that the person knows that you are acknowledging how difficult it is for them to be changing their behaviour.

Activity• One way of exploring pros and cons, is to

use a decisional balance worksheet with patients.

• This allows you to not only look at the pros and cons of changing, but also the pros and cons of not changing (in reality, there are positives to carrying out behaviours which are bad for us – otherwise we wouldn’t do them! It is important to acknowledge this as well as looking at the negatives of a given behaviour).

• Draw out your own decisional balance sheet, and either use a change which you would like to make, or make up an example (e.g. stop smoking, eat healthier diet, cut down alcohol).

Pros Cons

Change No Change

Overcoming Roadblocks and Resistance

• Action Plan - An action plan is a formal, written up plan of steps to take towards change. After setting a goal, ask the patient, how confident do you feel that you can achieve this goal on a scale of one to ten. If they give a number of 6 or lower, you might want to explore the reasoning behind this, and if needs be, change the goal until it becomes something which they actually feel confident that they can achieve.

• Praise Support and Reinforcement - It is important that all steps towards changing are acknowledged and praised, no matter how small they are. There is never a black and white divide of succeed and fail, think of these two points as being either side on a gradual scale:

Fail Made some progress Made moderate progress Made good progress Succeed

Overcoming Roadblocks and Resistance

• Amendments - Changing a goal to make it more achievable is not a failure; it may just be that the original goal was not realistic enough or not attainable at the current point in time. It is much better in the long run to amend goals and action plans than it is to stay focused on an unachievable goal.

• Rewards - When people are trying to change, it can be nice to know that at the end of each step there is a reward waiting for us. It doesn’t have to be something big or expensive, just something

which feels rewarding for that particular individual. • Pre-empt Slips/Relapse Prevention - The key to making

successful changes is to be aware of situations which might lead to us slipping up, be prepared for the possibility that we might slip up,

and plan for what we will do afterwards.

Summary• There are many reasons why an individual would want to change, or

would not want to change.• Our behaviour and motivations are all extremely personal, so telling

someone what they should do and why they should do it, very rarely works.

• Assess and facilitate motivation for change through motivational interviewing. Find out your patient’s motivation and let them do the reasoning (with a little guidance from yourself).

• Use the tactics outlined to overcome roadblocks to change and remember that most people will have slip ups/relapses – it is all part of changing.