Motivating Clients to Make Health Behavior Changes

1. Motivating Clients to Make Health Behavior Changes Deborah Hennrikus Joän Patterson Division of Epidemiology School of Public Health University of Minnesota

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

3. References Books: • Miller WR & Rollnick S. Motivational interviewing: Preparing people for change. New York: Guilford Press, 1991. • Rollnick S, Mason P & Butler C. Health behavior change: A guide for practitioners. New York: Churchill Livingstone, 1999. Website: • www.motivationalinterview.org Note: This website includes a full bibliography.

4. Problems with Standard Practice • Unwelcome advice elicits resistance • Knowledge weakly correlated with behavior • Variability in personal motivation • Advice must match motivation • Health care provider control better for acute care than behavior

5. Stages of Change decision change made occurs Precontemplation Contemplation Preparation Action Maintenance

6. Stage of Change Quick Assessment “How motivated are you, at the moment, to quit smoking? If 0 was ‘not at all motivated’ and 10 was ‘very motivated’, what number would you give yourself?” 010 Rollnick S. (1996). International Journal of Obesity, 20, Suppl 1, S22-S26.

7. Brief Negotiation Establish Rapport Choice of Behaviors Single Behavior Let Patient Select Raise Subject Assess Readiness to Change Not Ready Unsure Ready Inform and Encourage Understand Ambivalence Help Plan Action • S. Rollnick, P. Mason, W. Miller, 1994.

8. Motivational Interviewing:Some Theoretical Antecedents • Reactance (Brehm) Perceived threats to personal freedom and choice will elicit behaviors designed to demonstrate and restore freedom. The to-be-lost behavior becomes more desirable • Self-perception Theory (Bem) People learn by hearing themselves talk. When people publicly take a position, their commitment to that position increases. • Self-regulation Theory (Kanfer) Behavior is regulated by cycles involving the monitoring of one’s own status, comparison of status with expectations, and “course correction” when they don’t match *Miller WR, Rollnick S. Teaching Motivational Interviewing: Manual for Trainers, 1995.

9. “Spirit” of Motivational Interviewing • Client centered: Client determines treatment plan • Blank slate: Counselor’s job is to help client examine problem • Develop discrepancy: How does current behavior conflict with core values / future plans? • No unsolicited advice • Roll with resistance • Support self-efficacy • Good general counseling skills • Empathy • Non-verbal listening skills • Problem solving partners

10. Markers of a Productive MI Encounter • Client does most of the work • Client accepts the possibility of change • Client accepts responsibility for change • Upward slope of commitment language within or between sessions • Sessions are like dancing; not wrestling Ken Resnicow

11. Tools for Doing MI • Getting permission • Open-ended questions • Reflective listening • Eliciting self-motivational statements • Assessing 1-10 importance/confidence • Menus vs. single solutions • Summarizing

12. Getting Permission • When getting started • I would like to spend a few minutes talking about…… Is that okay with you? • When offering information or advice • I am aware of some strategies other people have found helpful in……. • Would you like to hear about some of these?

13. Ask Open-Ended Questions • Can’t be answered with “yes” or “no” • Ask 1 question at a time • Use respondent’s own words, when possible • Examples: • Tell me about…..? • Help me understand…..? • To what extent…..?

14. Reflective Listening • Affirms & validates your client • When clients feel understood, they are more likely to go deeper and say more • You are less likely to be judgmental • The “heart” of the MI approach • Rule of thumb: 5 reflective statements for every question

15. Levels of Reflective Listening • Restate: Use same word(s) • Rephrase: Use slightly different words • Paraphrase: Begin to interpret • Deduce: Deeper interpretations • Summative: Review & synthesize Going deeper

16. Reflective Listening Phrases • It sounds like you are unsure about …. • It’s been difficult for you to….. • You have been feeling discouraged about… • You are embarrassed that …… • You are not happy about…. • You believe that others view you negatively because…..

17. Levels of Reflective Listening • Content:“You see a connection between your smoking and the possibility of having another heart attack” • Feelings:“You are scared that if you continue smoking you might have another heart attack.” • Meaning:“Your children are important to you and you want to be there for them.”

18. Elicit “Change Talk” • Persons become more committed to doing what they actually say • Facilitate client statements of • Advantages of behavior change • Disadvantages of status quo • Optimism about being able to change • Intentions to change

19. Elicit “Change Talk” • Use importance/confidence ruler • Probe lower/higher • Explore decisional balance (ambivalence) • Respond to change talk • Reflecting • Elaborating • Affirming • Summarizing • Develop “discrepancy” between current behavior and core values

20. Menu vs. Single Solutions • Here are some things that have worked for other people……… • Which of these do you think might work for you? • Controlling your weight may involve several strategies, such as…….. • Which of these do you think are most important for you to work on?

21. Summarizing • “Let me see if I understand what you’ve told me sofar…..” • Focus on client’s statements regarding • Problem recognition • Reasons for change • If client is ambivalent, summarize both pros & cons • Optimism – confidence about change • Ask for feedback about your summary: “What have I missed?”

22. In Conclusion • Show respect, empathy • Do more listening than talking • Recognize/honor client’s autonomy • Recognize that solutions reside within your clients • Their motivation • Their behavior • Their values and goals