Motivating Behavior Change What Really Works?

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

2. Pre-Test

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

4. 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.

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

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

10. 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

11. Behavioral 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

12. Job descriptions • Providing facts: physician’s job • Interpreting personal implications (i.e. “importance”) of those facts: patient’s job

13. Lessons We Have Learned Information alone doesn’t work. Attempts to persuade create resistance Why is that?

14. 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

15. Contrary to our instincts…. • Attempts at persuasion just increase the stress!

16. Research 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.

17. How do people actually change? • “Stages of change” model(Prochaska and DiClemente) • Precontemplation • Contemplation • Preparation • Action • Maintenance Relapse

18. Physician’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”)

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

20. What is readiness? Ending point High I should, but I can’t. I’m ready! Importance (Why?) I could, but why should I bother? Huh? Low Starting point Low High Confidence (How?)

21. What is readiness? A change in importance usually happens first. High Importance Low Low High Confidence

22. What is readiness? Relapse High Maintenance Action Preparation The theory... Importance Contemplation Low Precontemplation High Low Confidence

23. What is readiness? The reality! High Importance Low Low High Confidence

24. What is readiness? The real reality…! High Importance Low Low High Confidence

25. Denial Reluctance Other-defined Reactance Argument Assessment: Precontemplation Patient O'Connell D., Ch. 16 Behavior Change in Feldman, Christensen "Behavioral Medicine in Primary Care"

26. Openness Weighs pros and cons Dabbles in action Can be obsessive Assessment: Contemplation Patient O'Connell D., Ch. 16 Behavior Change in Feldman and Christensen "Behavioral Medicine in Primary Care"

27. Understands need for change Begins to commit Can picture overcoming obstacles May procrastinate Assessment: Preparation Patient O'Connell D., Ch. 16 Behavior Change in Feldman and Christensen "Behavioral Medicine in Primary Care"

28. Describes plan Follows a plan Shows commitment Resists slips Remains vulnerable Assessment: Action Patient O'Connell D., Ch. 16 Behavior Change in Feldman and Christensen "Behavioral Medicine in Primary Care"

29. Has accomplished Notes improvement Aware of need for vigilance May lose ground New lifestyle may help make relapse less likely Assessment: Maintenance Patient O'Connell D., Ch. 16 Behavior Change in Feldman and Christensen "Behavioral Medicine in Primary Care"

30. Returns to problem behavior Begins as slips Cycles back to earlier stage Needs help to shorten relapse Assessment: Relapse Patient O'Connell D., Ch. 16 Bahavior Change in Feldman and Christensen "Behavioral Medicine in Primary Care"

31. Assessing readiness Relapse High Maintenance Action Preparation Importance Contemplation Low Precontemplation High Low Confidence

32. After assessment, how to help? • How can behavior change be facilitated by physicians? The answer is in the patient!

33. Link Behavior with Outcome; Establish Agenda • The patient’s agenda! • Ask directly about patient’s goals. • Linkpatient’s desired health outcometo a specific patientbehavior: “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.

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

35. Denial Reluctance Other-defined Reactance Argument 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.” Precontemplation Physician’s Basic Response Patient O'Connell D., Ch. 16 Behavior Change in Feldman, Christensen "Behavioral Medicine in Primary Care"

36. 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?” Contemplation Patient Physician’s Basic Response O'Connell D., Ch. 16 Behavior Change in Feldman and Christensen "Behavioral Medicine in Primary Care"

37. 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?” Preparation Physician’s Basic Response Patient O'Connell D., Ch. 16 Behavior Change in Feldman and Christensen "Behavioral Medicine in Primary Care"

38. 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?” Action Physician’s Basic Response Patient O'Connell D., Ch. 16 Behavior Change in Feldman and Christensen "Behavioral Medicine in Primary Care"

39. 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.” Maintenance Physician’s Basic Response Patient O'Connell D., Ch. 16 Behavior Change in Feldman and Christensen "Behavioral Medicine in Primary Care"

40. 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. Relapse Physician’s Basic Response Patient O'Connell D., Ch. 16 Bahavior Change in Feldman and Christensen "Behavioral Medicine in Primary Care"

41. Yet another mnemonic: • Double DARES • Develop Discrepancy • Avoid Argument • Roll with Resistance • Express Empathy • Support Self-efficacy

42. 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

43. 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

44. Avoid 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….”

45. 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.

46. 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.”

47. Express 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?”

48. Support 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.

49. Roadblocks to Behavior Change • Disagreeing, judging, blaming; • Warning, threatening; • Shaming, labeling.

50. More Roadblocks to Behavior Change • Moralizing (“shoulds”); • Persuading; • Challenging with questions; • Directing, ordering, commanding.