Behavior Change Counseling In a Public Health Setting Helping People Change Through Motivational Interviewing and Other Change Techniques Created by UCSF and the City of Berkeley Public Health Division Public Health Division Copyright © 2009 The Regents of the University of California, all rights reserved See for complete citationhttp://iha.ucsf.edu:16080/LiveWellBeWell/

Part 1 Motivational Interviewing Overview Motivational Interviewing Overview Harnessing Self-Efficacy Harnessing Self-Efficacy

Strengths of Motivational Interviewing Non-confrontational, empathic style Non-confrontational, empathic style Supported by research Supported by research Successful with different high risk populations Successful with different high risk populations Successful in brief sessions Successful in brief sessions Non-specialist can learn and use Non-specialist can learn and use

Motivational Support for Behavior Change: Promotes participant ownership of behavior change Promotes participant ownership of behavior change Uses open-ended questions and active, reflective listening Uses open-ended questions and active, reflective listening Supports participant’s intrinsic motivation, making change more likely to happen Supports participant’s intrinsic motivation, making change more likely to happen

A motivational coach DOES: Offer information, encouragement and support Offer information, encouragement and support Validate experiences and feelings Validate experiences and feelings Make change the responsibility of the participant Make change the responsibility of the participant

Ask yourself the following questions: Is participant reliant upon me to tell them what to do? Is participant reliant upon me to tell them what to do? Are the goals mine or theirs? Are the goals mine or theirs? Are they following my directions or learning transferable skills? Are they following my directions or learning transferable skills? Am I listening more or talking more? Am I listening more or talking more?

A motivational coach DOES NOT: tell a participant how to accomplish a life- style change; the participant defines how tell a participant how to accomplish a life- style change; the participant defines how try to convince a participant to make a change try to convince a participant to make a change diagnose or prescribe diagnose or prescribe

5 Principals of MI Express empathy Express empathy Work with ambivalence Work with ambivalence Avoid argumentation Avoid argumentation Roll with resistance Roll with resistance Support self-efficacy Support self-efficacy

Principal 1: Express empathy Counselor is an ally to participant Counselor is an ally to participant Participant should feel heard Participant should feel heard Counselor uses acceptance to create a safe atmosphere to explore alternatives Counselor uses acceptance to create a safe atmosphere to explore alternatives Skillful reflective listening is fundamental Skillful reflective listening is fundamental

Principal 2: Understanding Ambivalence Working with ambivalence is key Working with ambivalence is key Ambivalence is normal, acceptable, understandable Ambivalence is normal, acceptable, understandable Attachment to the behavior is part of ambivalence Attachment to the behavior is part of ambivalence Ambivalence tips back and forth Ambivalence tips back and forth

Signs of ambivalence Discrepancy: Discrepancy:  When what a person says and what a person does don’t match.  When a person says one thing and then in the next sentence says the opposite.

Using Discrepancy to Understand Ambivalence Interventions: Use the following kinds of statements to help participants understand their ambivalence Interventions: Use the following kinds of statements to help participants understand their ambivalence  “On the one hand…On the other hand…”  “So part of you wants…But another part of you feels…”

Working with Discrepancy: Balancing the Pros and Cons Benefits to Self and OthersCosts to Self and Others *More energy *Less Pain *Increased Stamina *Better mood *Increased strength *Lower blood pressure *Lower blood glucose *Too tired *Takes time *Difficult *Takes strength *Perspiring *Boring *Do I have to?

Moving Towards Less Ambivalence Benefits to Self and OthersCosts to Self and Others *More energy *Less Pain *Increased Stamina *Better mood *Increased strength *Might be fun *Lower blood pressure *Lower blood glucose *Play with grandchildren *Walk faster *Too tired *Takes time *Difficult *Takes strength *Perspiring

Other Ways to Explore Ambivalence How Important Ruler Not At All ImportantExtremely Important Ask participant: “How important is this change?” “Why Not Lower?”

Principal 3: Avoid Argumentation Giving advice, making suggestions or providing solutions Giving advice, making suggestions or providing solutions Persuading with logic, arguing or lecturing Persuading with logic, arguing or lecturing Disagreeing, judging or diagnosing Disagreeing, judging or diagnosing Withdrawing, distracting, humoring or changing the subject Withdrawing, distracting, humoring or changing the subject

Principal 4: Roll with Resistance Roll, rather than confront resistance. Let participant know resistance is OK. Roll, rather than confront resistance. Let participant know resistance is OK.  Confronting resistance can cause participant to dig in. Strategies to help resolve resistance: Strategies to help resolve resistance:  Explore pros and cons of change  Use “Decisional Balance” tool Continued resistance equals a signal to change our approach. Continued resistance equals a signal to change our approach.

Principal 5: Support Self-Efficacy Self beliefs are important Self beliefs are important People gain self-efficacy by seeing others succeed. People gain self-efficacy by seeing others succeed. Participant can borrow self-efficacy from counselors or others. Participant can borrow self-efficacy from counselors or others.

Harnessing Self-Efficacy: “I know I can do it!” The belief in your ability to do something will mediate whether or not it is tried, how much effort goes into it, and how long you will persist in your efforts. The belief in your ability to do something will mediate whether or not it is tried, how much effort goes into it, and how long you will persist in your efforts. Explore with participant a time when they were successful at physical activity or healthy eating. Explore with participant a time when they were successful at physical activity or healthy eating.

One Way to Gain Self-Efficacy is Seeing Others Succeed: Role Modeling: Role Modeling:  “If they can do it, maybe I can too.” Ask, “Who do you know who has been able to accomplish this?” Group activities and workshops can help to inspire and motivate participants. Group activities and workshops can help to inspire and motivate participants.

Borrowing Self-Efficacy Expressing faith in the participant helps participant have faith in self. Expressing faith in the participant helps participant have faith in self. Participants can tap into other’s belief that they can accomplish their goals. Participants can tap into other’s belief that they can accomplish their goals. Ask, “Who in your family thinks you can do this?” Ask, “Who in your family thinks you can do this?”

Part 2 Stages of Change Stages of Change Goal Setting and Action Plans Goal Setting and Action Plans Potential Obstacles and Solutions Potential Obstacles and Solutions

Stages of Readiness to Change Behavior Pre-contemplation Contemplation Preparation Action Maintenance Relapse & Recycle

Stages of Change Action Preparation Contemplation Pre- contemplation Maintenance Hmm…

Signs of Readiness to Change Less resistance Less resistance Fewer questions about the problem Fewer questions about the problem Self-motivational statements Self-motivational statements More questions about change More questions about change Looking ahead Looking ahead Experimenting with change Experimenting with change

Quick Ways to Elicit Change Talk How Ready Ruler Not At All ReadyExtremely Ready Ask participant: “How ready are you to make this change?” “Why not lower?”

Providing Support According to the Stages of Change StageTask Pre-contemplation (stage 1) -Discuss client’s feelings and experiences -Don’t assume client is ready to change -Educate re. Health -Start small

Providing Support According to the Stages of Change StageTask Contemplation (stage 2) -Talk about benefits and barriers to change -Identify participant’s personal reasons for wanting to make change -Have client identify his/her own motivation -Encourage short term, achievable goal setting

Providing Support According to the Stages of Change StageTask Preparation (stage 3) -Be Supportive -Reinforce all positive progress -Help client build self confidence -Help client monitor gains and decrease barriers

Providing Support According to the Stages of Change StageTask Action (stage 4) -Provide continued encouragement -Discuss ways to slowly increase frequency, intensity and time (FIT) -Help participant to plan ahead for changes in routine, such as vacations or illness, so that they can stay on track

Providing Support According to the Stages of Change StageTask Maintenance (Stage 5) -Praise and feedback still important -Offer community resources in case the client’s routine becomes boring or he/she wants new challenges -In case of relapse, have a plan for getting back in action -Remind them that lapses are temporary and can be viewed as a learning situation rather than a failure

Goal Setting Short term and long term goals Short term and long term goals Achievable, specific and measureable goals Achievable, specific and measureable goals Assessing confidence Assessing confidence  Setting unrealistic goals erodes self efficacy Troubleshooting obstacles Troubleshooting obstacles  Brainstorming how to overcome them

Action Plans I will_______________________________ I will_______________________________ On a scale of 1-10, how confident am I that I can do it?__________________________ On a scale of 1-10, how confident am I that I can do it?__________________________ What could make it difficult to do?________________________________ What could make it difficult to do?________________________________ What can I do to overcome the difficulties?__________________________ What can I do to overcome the difficulties?__________________________

Achievable Goals Confidence Ruler Not At All ConfidentExtremely Confident Ask participant: “How confident are you that you can make this change?” “Why not lower?”

My Action Plan I will go to the gym 3 times this week I will go to the gym 3 times this week On a scale of 1-10, how confident am I that I can do it? 7 On a scale of 1-10, how confident am I that I can do it? 7 What could make it difficult to do? I’m so busy and tired after work What could make it difficult to do? I’m so busy and tired after work What can I do to overcome the difficulties? Go on my lunch break two days and one time on the weekend What can I do to overcome the difficulties? Go on my lunch break two days and one time on the weekend

The Challenging Participant Talkative Talkative Emotionally needy Emotionally needy Abrupt or hostile Abrupt or hostile Hard to reach Hard to reach In need of additional resources In need of additional resources  Mental health  Alcohol and drugs  Medical issues  Cognitive deficits

Self-care and Supervision Setting boundaries Setting boundaries Create a workable schedule Create a workable schedule Establish protocol for referrals Establish protocol for referrals Join or create a peer support group Join or create a peer support group Seek consultation and supervision Seek consultation and supervision