Motivating Patients to Change Unhealthy Behavior Dr. Allan R. Dionisio

Motivational Interviewing and the Stages of Change Based on chapter 13 written by Carlo DiClemente From the book Motivational Interviewing

Motivation The base word is “motion”—referring to action or movement. Another word about “motion” is EMOTION. Knowledge is not enough. Knowledge must be combined with EMOTION in order to be motivated.

Think of a behavior that you have wanted to change for the longest time, but you haven’t gotten around to changing.

Motivation The base word is “motion”—referring to action or movement. Another word about “motion” is EMOTION. Knowledge is not enough. Knowledge must be combined with EMOTION in order to be motivated.

PGH Protocol for Resistant Pts Paliwanagan mo. Kulitin mo. Takutin mo. Pagalitan mo. Papirmahin mo.

What do you do when you can’t scare them? (… when other emotions are greater than fear?)

6 Stages of Change According to Prochaska and DiClemente Pre-Contemplation Contemplation Determination Action Maintenance and relapse prevention Termination

The Objective of the Session The goal is not so much to reach the Action stage in one session… …but rather to move the patient from his present stage to the next one. (ideal context--a continuing relationship)

Know what stage your patient is in, then plan accordingly.

Specific techniques (See if you have tried these already!)

Pre-Contemplation Patient is not even thinking about changing his behavior. In fact, they may not see the behavior as a problem at all.

Pre-Contemplation The 4 “R”s RELUCTANCE REBELLION RESIGNATION RATIONALIZATION

Pre-Contemplation RELUCTANCE They do not want to consider change because of LACK OF KNOWLEDGE or INERTIA. APPROACH: provide feedback and information in a sensitive and empathic manner

Pre-Contemplation REBELLION They have a heavy investment in the problem behavior and in making their own decisions. Resistant to being told what to do. Appears hostile. APPROACH: Offer choices Shift some of the energy used to resist into contemplating change

Pre-Contemplation RESIGNATION Characterized by lack of energy and investment They have given up on the possibility of change and seem overwhelmed by the problem. APPROACH: Instill hope Explore barriers to change

Pre-Contemplation RATIONALIZATION Many reasons why the problem is not a problem or is a problem for others but not for them. Session feels like a debate APPROACH: Empathy and reflective listening; the double-sided reflection (“On the one hand…, but on the other…”)

Pre-Contemplation Some important considerations: You have to distinguish between rationalization and informed choice. We cannot assume that “the problem” means the same to the patient as it does to us. It is not true that “more is always better” More education, more intense treatment, and more confrontation does not necessarily produce more change.

Contemplation Patient is willing to consider the problem and is quite open to information and decisional balance considerations… BUT there is much ambivalence. Remember that contemplation/interest is not the same as commitment.

Contemplation APPROACH Provide information and incentives to change… …but make the information palpable and relevant to them personally. Deal equally to the hidden “benefits” of maintaining the behavior (“decisional balance technique”) Deal equally with the pros and cons of CHANGING the behavior

Decisional Balance Technique Prochaska and DiClementi

Motivation—observe the use of emotion in the technique The base word is “motion”—referring to action or movement. Another word about “motion” is EMOTION. Knowledge is not enough. Knowledge must be combined with EMOTION in order to be motivated.

5 Questions in Series What do you get out of it? What are the disadvantages? What are your goals in life? How does the behavior fit into your goal? If you could change, what would happen?

Question 1: What do you get out of it?

Question 2: What are the disadvantages?

Question 3: What are your goals in life?

Question 4: How does the behavior contribute to your goals?

Question 5: If you could change, what would happen?

Set a quit date. Make a plan that fills legitimate needs and hurdles obstacles.

5 Questions in Series What do you get out of it? What are the disadvantages of your behavior? What are your goals in life? How does your behavior contribute to your goals? If you could change, what would happen?

Contemplation APPROACH Explore problems with previous attempts to change. Reframe failures into “partial successes”. Emphasize the cyclic nature of change in the stages- of-change model. Anticipate the barriers to change.

Determination: Commitment to Action Hallmark: deciding to take appropriate steps to stop a negative behavior or start a positive one Assess strength and levels of commitment Anticipate problems and pitfalls Use appropriate techniques. (Enthusiasm is not a cure for ineptness.)

Action Provide confirmation of the plan Provide support Provide external monitoring of progress Focus on successful activity (“Progress, not perfection.”) Reaffirm their decision Offer information about successful models Usually lasts 3-6 months

Maintenance, Relapse, Recycling New behavior is becoming firmly established Threat of relapse becomes less frequent and intense BUT relapse is always possible APPROACH Provide feedback about length of time needed for change Help patient become aware of “triggers” Help the patient learn from the relapse Remind them of the cycle of change