Talking about Talking about Behaviour Change: A Behaviour Change: A brief introduction to brief introduction to

Motivational Motivational InterviewingInterviewing

Dr. Dean D. SnowDr. Dean D. Snow

Psychology DepartmentPsychology Department

Dr. Everett Chalmers HospitalDr. Everett Chalmers Hospital

Understanding Behaviour Understanding Behaviour ChangeChange

• Why do people change...or stay the Why do people change...or stay the same?same?

• You would think...right ?You would think...right ?– Having a heart attack or stroke would make Having a heart attack or stroke would make

you quit smokingyou quit smoking– Having a Having a TIA would make you take your TIA would make you take your

antihypertensivesantihypertensives– Developing angina would make you want to Developing angina would make you want to

lose weightlose weight

Traditional Approach to Traditional Approach to Health Behaviour Health Behaviour

ChangeChangePatient Patient EducationEducation

Patient

Summary of Research on Summary of Research on Health Behaviour ChangeHealth Behaviour Change

• Traditional strategies for increasing motivation Traditional strategies for increasing motivation (e.g. fear induction, education, threats, directive (e.g. fear induction, education, threats, directive methods) create reactance and resistancemethods) create reactance and resistance

• Place patient in passive rolePlace patient in passive role• Risk appraisalRisk appraisal• Problem behaviours are hard to change Problem behaviours are hard to change

regardless of motivationregardless of motivation• People who change move through stagesPeople who change move through stages• Permanent change usually requires several Permanent change usually requires several

attemptsattempts

Understanding Behaviour Understanding Behaviour ChangeChange

• What is motivation ? Ready, willing & ableWhat is motivation ? Ready, willing & able– WillingWilling

• Desire or will for change; perceived importanceDesire or will for change; perceived importance• Discrepancy between status & goal; self-regulationDiscrepancy between status & goal; self-regulation• Low Importance pathological ?Low Importance pathological ?

– AbleAble• Confidence for change; self-efficacyConfidence for change; self-efficacy• Defenses against failureDefenses against failure

– ReadyReady• Is change a priority Is change a priority nownow??

Understanding Behaviour Understanding Behaviour ChangeChange

• What triggers change?What triggers change?– Avoidance of discomfort ?Avoidance of discomfort ?– Change & Intrinsic motivationChange & Intrinsic motivation

• Connection to cherished valuesConnection to cherished values• Arises in an accepting, empowering atmosphereArises in an accepting, empowering atmosphere• Arises from exploration of ambivalenceArises from exploration of ambivalence

Understanding Behaviour Understanding Behaviour ChangeChange

• What is ambivalence ?What is ambivalence ?

– Feeling two ways: I want to but I don’t want toFeeling two ways: I want to but I don’t want to• Addiction, Infidelity, SmokingAddiction, Infidelity, Smoking

– Pathology or Human Nature?Pathology or Human Nature?– Ambivalence: A phase in the process of Ambivalence: A phase in the process of

changechange

What is my role as a health What is my role as a health professional ?professional ?

• Behaviour change agent ?Behaviour change agent ?• ““Fix-it” roleFix-it” role

– Provide advice, direction, education whether patient is Provide advice, direction, education whether patient is ready or notready or not

– Practitioner centeredPractitioner centered– Patient in passive stancePatient in passive stance

• Motivational RoleMotivational Role– Focus on benefits, risksFocus on benefits, risks– Give advice if requestedGive advice if requested– Relate in flexible waysRelate in flexible ways– Client centered, client an active participantClient centered, client an active participant

Promoting Behaviour Promoting Behaviour ChangeChange

• Value BaseValue Base

– Respect for Patient Respect for Patient AutonomyAutonomy

• SkillsSkills

– Confrontational Confrontational interviewing style can interviewing style can be unproductivebe unproductive

– Information exchange is Information exchange is a critical skilla critical skill

– Readiness to change Readiness to change should be monitoredshould be monitored

– Assess Assess importance importance and and confidenceconfidence

• Roles - PractitionerRoles - Practitioner– Provide structure, Provide structure,

direction, supportdirection, support– Provides information Provides information

wanted by the patientwanted by the patient– Elicits and respects Elicits and respects

patients viewspatients views– Negotiates change Negotiates change

sensitivelysensitively• Roles - PatientRoles - Patient

– Is an active decision-Is an active decision-makermaker

Enhancing MotivationEnhancing Motivation

Establish RapportEstablish Rapport

Set AgendaSet Agenda

Assess Importance Assess Importance and Confidenceand Confidence

Single BehaviourSingle Behaviour

Multiple Multiple BehavioursBehaviours

Build Build ConfidenceConfidence

Explore Explore ImportanceImportance

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Thomas, 1970

Active ListeningActive Listening

PatientPatient ClinicianClinician

What the PatientWhat the Patient meansmeans

What the Clinician What the Clinician UnderstandsUnderstands

11

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What the What the Patient saysPatient says

What the Clinician What the Clinician hearshears

Establish RapportEstablish Rapport

• Take your timeTake your time

• Preparation for discussion of behaviour Preparation for discussion of behaviour changechange

• Prior relationship vs. New consultPrior relationship vs. New consult

• Physical settingPhysical setting

• Patient thoughts and feelingsPatient thoughts and feelings

• Strategy: A typical dayStrategy: A typical day

Setting AgendaSetting Agenda

• Ask permission to raise the issueAsk permission to raise the issue– ““Would it be okay if you and I talked a bit about Would it be okay if you and I talked a bit about

your progress in treating your high BP?”your progress in treating your high BP?”

• Neutral Information ExchangeNeutral Information Exchange– Elicit – Provide – ElicitElicit – Provide – Elicit

• ““How concerned are you about your blood pressure How concerned are you about your blood pressure levels”levels”

• ““We know that exercise helps lower your blood We know that exercise helps lower your blood pressure.”pressure.”

• ““What do What do youyou think of that?” think of that?”

Assess Importance & Assess Importance & Confidence Confidence

• Informal Assessment Informal Assessment – Open-ended questions Open-ended questions – Elicit patient thoughts about value of change & Elicit patient thoughts about value of change &

obstacles to itobstacles to it

• Formal AssessmentFormal Assessment– Use ratings or rulerUse ratings or ruler

• ““How important is it, How important is it, at this moment,at this moment, for you to get for you to get better control over your BP ?”better control over your BP ?”

• ““How confident do you feel about increasing your How confident do you feel about increasing your activity level?”activity level?”

Explore Importance & Explore Importance & ConfidenceConfidence

• ImportanceImportance• ““What would have to happen for your smoking to What would have to happen for your smoking to

become much more important for you to change?”become much more important for you to change?”• ““Why is your importance score 6 and not 0?” “What Why is your importance score 6 and not 0?” “What

are things you like (and dislike) about you’re your are things you like (and dislike) about you’re your alcohol use?”alcohol use?”

• ““What would need to change for your Importance What would need to change for your Importance score to move from 5 to 9?”score to move from 5 to 9?”

• ConfidenceConfidence• ““What would make you more confident about What would make you more confident about

succeeding in losing weight?”succeeding in losing weight?”• ““What have you found helpful when you What have you found helpful when you

succeeded in hard tasks in the past?”succeeded in hard tasks in the past?”

Exploring Importance & Exploring Importance & ConfidenceConfidence

• ““How do you feel about your progress How do you feel about your progress so far?”so far?”

• ““How concerned are you about your How concerned are you about your smoking?”smoking?”

• ““What do you think you need to do in What do you think you need to do in order to get better ?”order to get better ?”

• ““How confident are you that you could How confident are you that you could quit smoking if you put your mind to it?”quit smoking if you put your mind to it?”

Reduce ResistanceReduce Resistance

• What is it ?What is it ?• What Causes it ?What Causes it ?• Avoiding resistance trapsAvoiding resistance traps

– Take control awayTake control away– Misjudge importance, confidence, readinessMisjudge importance, confidence, readiness– Meet force with forceMeet force with force

• Dealing with resistanceDealing with resistance– Emphasize personal choice & controlEmphasize personal choice & control– Reassess readiness, importance and confidenceReassess readiness, importance and confidence– Back off and come alongside the patientBack off and come alongside the patient