Michael Vallis, PhD R Psych Psychologist and Lead, CH Behaviour Change Institute Associate Professor, Dalhousie University Motivational Interviewing: The Challenging Patient & Interactive Case Studies 4th Annual Chronic Disease Self-Management Conference

Let’s Start With What We Know The strongest predictor of future behaviour is ? PAST BEHAVIOUR! What does this say about the likelihood of behaviour change? NOT!

And, by the way, the strongest predictor of changed behaviour is ? SELF-EFFICACY A person’s confidence to perform a specific behaviour in a specific context for a specific time period and in the face of specific barriers

Self-Management Support Skills 1. Relationship skills - establishing a change based relationship using motivational interviewing 2. Motivational skills - getting to the behaviour 3. Behaviour change skills - making sustainable changes 4. Emotion management skills - helping to maintain the behaviour

What Does Self-Management Support Really Mean? Fundamental change in the relationship between the individual and the HCP From Expert clinician with uninformed helpseeker “Let me tell you what you need to do” “Let me tell you what you need to know” To We both have a role to play “I understand that you will make your own decisions and I respect that. Can we have a conversation about your health”

Change-Based Relationships A helping alliance involves 3 components: Bond Task Goal

Motivational Interviewing Ask questions, Minimize statements Express Empathy Take a curious, nonjudgmental stance Learn to sit with ambivalence Avoid argument Roll with resistance Support Self-Efficacy

Determine Readiness Is the behaviour (or lack of it) a problem for you? Does the behaviour (or lack of it) cause you any distress? Are you interested in changing your behaviour? Are you ready to do something to change your behaviour now?

Getting to the Behaviour Readiness Assessment Not Ready Ready Go Right to Behaviour Modification Ambivalent Understanding the behaviour Personal meaning Seriousness, personal responsibility, controllability, optimism Expanding on readiness Personal/meaningful reasons to change Willingness to work hard - connect to principles Delay of gratification Barriers/Temptations Especially social, cultural and environmental Decisional Balance Self-Efficacy

Working With the Behaviour: Behaviour Modification Goal Setting SMART GOALS Specific, measurable, achievable, relevant, timely Shaping Importance of NEXT STEP Stimulus control Respecting the environment Reinforcement Management

Maintaining Change: Emotion Management Your Task Identify Educate Recommend Support

Managing Emotions Dealing with unhealthy coping strategies Recognize the value of unhealthy behaviour and focus on replacing the function Stress Management Physical discharge Physical calming Express emotions Seek social support Referral for psychological intervention

“I want to eat what I want, when I want” “I feel fine, I am sure if my diabetes was a problem I would feel sick?” “Everytime you follow advice new research gets released that says the old way was better”

CASES 50 yo single female living with elderly mom (depressed drinker), - diabetes COPD dysthymic - she is stuck - not moving 17 adolescent male - grass - referred from school - cocaine and alcohol - struggle to avoid situations -he’s becoming concerned 19 yo referred from probation (drinking/driving) - meets regularly - says wants to make changes (don’t believe him) - “are you here because of probation” - ambivalent but slippery 70 yo female - smoker (1ppd) - relapse when stressed - motivated - COPD, ca, diabetic and bipolar