Dancing, not wrestling How to reach a shared management plan with a patient whom you want to change their behaviour Maggie Eisner www.bradfordvts.co.uk

Helping people change behaviour - your experience Think of a patient whom you tried to help to change What did you try? What worked? What didn’t work? Any ideas about why it worked/didn’t work?

Change Change isn’t a simple discrete event, it’s a process Sometimes a crisis can precipitate a sudden change Change usually involves loss as well as the perceived gain Stages of Change – precontemplation, contemplation, change

The cycle of change

Our role Traditional advice-giving isn’t useless but absolutely depends on timing Need to understand the behaviour’s meaning for the patient - how do they see the benefits and problems of the change? Help patient prepare for change Encourage to experiment with small steps Provide information when the patient is receptive Accept that people have relapses (and help patient accept this too)

Motivational interviewing A video from the USA

Principles We need to enable the patient to Dancing vs wrestling Believe that change is important Have confidence in their ability to change Dancing vs wrestling Start positive

Tools The dinner plate, to choose which behaviour to change first Scaling questions (1-10 scale) How important is this change to you? How confident are you that you can change? Find out – suggest – find out more (Elicit – Provide – Elicit) What do they know/want to know? What do they see as their options? What might their family and friends think? What do they think? Help them set realistic goals/targets which they think will work – concentrate on the next small step

Pitfalls (or potholes) Patients Helplessness Agree it’s hard, empathise Help them recall past successes Resistance Summarise what they’ve said (instead of getting into an argument) Clinicians Lecturing Go back to asking questions about the patient’s point of view Cheerleading Bring the focus back to the patient

Go back to the case you talked about Can you think of how you might have been more effective?

Dance, don’t wrestle … Help patient believe change is important Help them get confidence they can change Start positive Dinner plate Scaling questions Find out – suggest – find out more Help patient set realistic target – what’s the next small step? If pt helpless, empathise, remind of past success If pt resistant, summarise what they’ve said Stop lecturing and get back to pt’s point of view Stop cheerleading, get back to pt’s point of view

After tea – skills practice Scenarios for groups of 3 (doctor, patient, observer) – preferably Mixed ST years People you don’t know well Patient – study scenario and get deeply into role Observer – note specific things the doctor did well or could have done better Feedback – doctor first (How did you think you did? What did you do well? What do you think you would have liked to do better?), then patient, then observer Feedback should help the doctor – either affirm what they did well, or specific ideas about what they could do differently (Without specific suggestions, you were really good is as unhelpful as you were rubbish)

Something to think about over tea Have you ever wanted to change your behaviour? What helped/hindered you?