Motivating Behavior Change What Really Works? Practice of Medicine I Christine M. Peterson, M.D. David Waters, Ph.D.

Motivating Behavior ChangeWhat Really Works?

Motivating Behavior ChangeWhat Really Works?

Practice of Medicine I

Christine M. Peterson, M.D.

David Waters, Ph.D.

Pre-TestPre-Test

Mokdad et al., JAMA 2004;291(10)1238-1245.

Do You Know?Do You Know? Half of all deaths in the US are attributable to

personal behavior, including: Tobacco = 435,000 deaths (one of every 5) Poor diet and physical inactivity

= 365,000 deaths Alcohol = 85,000 deaths Drugs = 17,000 deaths Other: Homicide, suicide, some accidents,

etc.

Do You Know?Do You Know? Half of all patient visits require a

behavior change on the part of the patient as part of treatment Meds Diet Exercise Safer sex practices Substance avoidance Etc., etc., etc.

How to help?How to help?

How can we help our patients to change their behavior in health-promoting ways?

“Motivational Interviewing”“Motivational Interviewing”

“A directive, client-centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence.”- Rollnick and Miller, 1995

Goals of this segment of PoM Goals of this segment of PoM

To gain a better understanding of the difficulty and complexity of behavior change

To practice approaching a patient in an open and non-judgmental manner

Behavioral objectives for studentsBehavioral objectives for students

To maintain an open and curious approach

To learn about techniques useful in motivating behavior change, esp. exploring ambivalence and limiting resistance

To learn about own attitudes and beliefs about changing behavior

Job descriptionsJob descriptions

Providing facts: physician’s job Interpreting personal

implications (i.e. “importance”) of those facts: patient’s job

Lessons We Have LearnedLessons We Have Learned

Information alone doesn’t work.

Attempts to persuade create resistance

Why is that?

Why do people develop negative habits?Why do people develop negative habits?

In an effort to feel better!

External factors: life stresses Internal factors:

inadequate coping skills emotional issues physiological reinforcement congruence of behavior and identity

Contrary to our instincts….Contrary to our instincts….

Attempts at persuasion just increase the stress!

Research findings:Behavior change = Adult learningResearch findings:Behavior change = Adult learning

Self-initiated and self-directed Practical, useful, applicable to real life

(problem-solving) Incorporates feedback about efforts

In clinical setting, physician should be: partner, not expert; coach, not parent; mirror, not (magic) bullet.

How do people actually change?How do people actually change?

“Stages of change” model(Prochaska and DiClemente)

Precontemplation

Contemplation

Preparation

Action

MaintenanceRelapse

Physician’s role in behavior changePhysician’s role in behavior change

Goal = Help patient move ahead to the next stage First, accurately assess patient’s

current stage Then, facilitate movement to next

stage (”double DARES”)

Adult behavior change:Adult behavior change: What to do? Why to do it? (= “Importance”) How to do it? ( = “Confidence”)

What is readiness?What is readiness?

Confidence (How?)

Low High

Importance (Why?)

High

LowHuh?

I should, but I can’t.

I could, but why should I bother?

I’m ready!

Starting point

Ending point


ConfidenceLow High

Importance

High

Low

A change in importance usually happens first.


ConfidenceLow High

Importance

High

Low Precontemplation

Contemplation

Preparation

ActionMaintenance

The theory...

Relapse


ConfidenceLow High

Importance

High

Low

The reality!


Confidence

Low High

Importance

High

Low

The real reality…!

O'Connell D., Ch. 16 Behavior Change in Feldman, Christensen "Behavioral Medicine in Primary Care"

Assessment: PrecontemplationAssessment: Precontemplation

Denial Reluctance Other-defined Reactance Argument

Patient

O'Connell D., Ch. 16 Behavior Change in Feldman and Christensen "Behavioral Medicine in Primary Care"

Assessment: ContemplationAssessment: Contemplation

Openness Weighs pros and cons Dabbles in action Can be obsessive

Patient


Assessment: PreparationAssessment: Preparation

Understands need for change Begins to commit Can picture overcoming

obstacles May procrastinate

Patient


Assessment: ActionAssessment: Action

Describes plan Follows a plan Shows commitment Resists slips Remains vulnerable

Patient


Assessment: MaintenanceAssessment: Maintenance

Has accomplished Notes improvement Aware of need for vigilance May lose ground New lifestyle may help make

relapse less likely

Patient

O'Connell D., Ch. 16 Bahavior Change in Feldman and Christensen "Behavioral Medicine in Primary Care"

Assessment: RelapseAssessment: Relapse

Returns to problem behavior Begins as slips Cycles back to earlier stage Needs help to shorten relapse

Patient

Assessing readinessAssessing readiness

ConfidenceLow High

Importance

High

Low Precontemplation

Contemplation

Preparation

ActionMaintenance

Relapse

After assessment, how to help?After assessment, how to help?

How can behavior change be facilitated by physicians?

The answer is in the patient!

Link Behavior with Outcome; Establish Agenda Link Behavior with Outcome; Establish Agenda

The patient’s agenda! Ask directly about patient’s goals. Link patient’s desired health outcome to a

specific patient behavior: “You have [condition] …...And that

is causing your [symptom or problem]. I think it might help to consider [behavior change] ...……”

Establish patient’s agenda: “What do you think?” Avoid assigning physician’s agenda.

“Motivational Interviewing”“Motivational Interviewing”



PrecontemplationPrecontemplation


Strategy: When the patient is ready, I’ll be here.

“I have some concern, but if you don’t, I’ll accept that for now.”

Physician’s Basic ResponsePatient


ContemplationContemplation

Openness Weighs pros and

cons Dabbles in action Can be

obsessive

Strategy: Go slow, reflect, don’t rush, nurture the idea.

“Would you like to work on this with my help?”

Patient Physician’s Basic Response


PreparationPreparation

Understands need for change

Begins to commit Can picture

overcoming obstacles

May procrastinate

Strategy: Don’t jump too fast, don’t assume too much; don’t take over.

“How can I help as you get ready?”



ActionAction

Describes plan Follows a plan Shows

commitment Resists slips Remains

vulnerable

Strategy: Stay positive and supportive, help with weak spots.

“What do you need from me to keep this going?”



MaintenanceMaintenance

Has accomplished Notes

improvement Aware of need for

vigilance May lose ground New lifestyle may

make relapse unlikely.

Strategy: Look for lessons from past for future use.

“I’m rooting for you.”



RelapseRelapse

Returns to problem behavior

Begins as slips Cycles back to

earlier stage Needs help to

shorten relapse

Strategy: Do you want to stay on it and start again?

“I’m not discouraged; let’s talk about when (not ‘if’) to try again.


Yet another mnemonic:Yet another mnemonic:

Double DARESDouble DARES Develop Discrepancy Avoid Argument Roll with Resistance Express Empathy Support Self-efficacy

Develop Discrepancy;;Establish Ambivalence

Develop Discrepancy;;Establish Ambivalence

Have patient describe the discrepancy between their current behavior and what they have told you is important to them ambivalence.

Have them present the reasons for change in terms of their desired outcome

Establish Ambivalence; Pros and Cons Establish Ambivalence; Pros and Cons

Examine pros and cons - help patient identify problem area or area of concern

• Good things less good things about current behavior

• Re-state their reasoning for andagainst change

Avoid ArguingAvoid Arguing• Be aware of threat of loss of

freedom• “It should never be you against the

patient; it should be the part of the patient that wants to change against the part that doesn’t….”

Roll with Resistance (description)Roll with Resistance (description)

Arises whenever there is tension or disagreement

Results from traps: Taking control awayMisjudging importance, confidence or readinessMeeting force with force

Manifests in: ignoring, inattention, discounting, excusing, blaming, hostility, splitting, etc.

It is a sign that rapport needs attention.

Roll with Resistance (management)Roll with Resistance (management)

It is your cue to change strategies. Strategies:

Emphasize personal choice and controlReassess stage and/or readiness (importance, confidence)

Back off and come alongside the patient Stay committed but curious. “It’s like dancing - you have to stay relaxed.”

Express EmpathyExpress Empathy

Express empathy without accepting the status quo.

“I can understand that you might feel that way.”

“Yes, it sounds pretty difficult, doesn’t it?”

Support Self-efficacySupport Self-efficacy

Fearful Information: No one wants it! ONLY WHEN PATIENT REQUESTS,

provide information Patient’s interest :

“What have you heard about….?” “I wonder, would you be interested in

knowing more about…. Avoid having the patient put you in the

“Yes, but…” trap.

Roadblocks to Behavior ChangeRoadblocks to Behavior Change

Disagreeing, judging, blaming; Warning, threatening; Shaming, labeling.

More Roadblocks to Behavior ChangeMore Roadblocks to Behavior Change

Moralizing (“shoulds”); Persuading; Challenging with questions; Directing, ordering, commanding.


Giving advice, suggestions, solutions;

Agreeing, approving, praising based on physician’s agenda.


Reassuring, consoling; Interpreting, analyzing; Withdrawing, humoring.

Maintaining Behavior Change: The 3 F’s Maintaining Behavior Change: The 3 F’s

Timely follow-up by physician (or team member)

Feedback Non-judgmental “When you …… , then ……

occurred.” Focused on patient’s agenda

Post-TestPost-TestPost-TestPost-Test

Motivating Behavior ChangeMotivating Behavior ChangePart 2Part 2

Motivating Behavior ChangeMotivating Behavior ChangePart 2Part 2

Practice of Medicine I

Christine Peterson, M.D.David Waters, Ph.D.

““Motivational Interviewing”Motivational Interviewing”““Motivational Interviewing”Motivational Interviewing”


Keep in mind:Keep in mind:

Double DARESDouble DARES Develop Discrepancy Avoid Argument Roll with Resistance Express Empathy Support Self-efficacy


Moving Beyond PrecontemplationMoving Beyond Precontemplation


Permission Inquiry Discrepancies Concern Asks pt. to

think between visits

Physician’s TacticsPatient


Moving Beyond ContemplationMoving Beyond Contemplation

Openness Weighs pros

and cons Dabbles in

action Can be

obsessive

Elicits pt’s perspective

Helps with pros and cons

Asks about promoters

Suggests trials

Patient Physician’s Tactics


Moving Beyond PreparationMoving Beyond Preparation

Understands need for change

Begins to commit Can picture

overcoming obstacles

May procrastinate

Summarizes pt’s reasons

Negotiates a start date

Encourages public statement

Arranges follow-up



Moving Beyond ActionMoving Beyond Action

Describes plan Follows a plan Shows

commitment Resists slips Remains

vulnerable

Shows interest Supports pros Slip vs relapse Anticipates

handling slip Helps to modify Arranges follow-up



Staying with MaintenanceStaying with Maintenance

Has accomplished Notes

improvement Aware of need for vigilance

May lose ground Lifestyle may

preclude relapse

Shows support Inquires re feelings Asks about slips Helps plan for

intensifying effort Supports lifestyle Reflects on

permanence of change

Physician’s TacticsPatient


Recovering from RelapseRecovering from Relapse

Returns to problem behavior

Begins as slips Cycles back to

earlier stage Needs help to

shorten relapse

Frames as learning opportunity

Asks for specifics Reminds reasons are

valid “When” not ‘if” pt.

changes again Normalizes


Maintaining Behavior Change: The 3 F’s Maintaining Behavior Change: The 3 F’s

Timely follow-up by physician (or team member)

Feedback Non-judgmental “When you …… , then ……

occurred.” Focused on patient’s agenda

Role Play Time……Role Play Time……

Motivating Behavior Change What Really Works? Practice of Medicine I Christine M. Peterson, M.D. David Waters, Ph.D.

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