1. Talking about Behaviour Change: A brief introduction to Motivational Interviewing Dr. Dean D. Snow Psychology Department Dr. Everett Chalmers Hospital

2. Understanding Behaviour Change Why do people change...or stay the same?Why do people change...or stay the same? You would think...right ?You would think...right ? –Having a heart attack or stroke would make you quit smoking –Having a TIA would make you take your antihypertensives –Developing angina would make you want to lose weight

3. Traditional Approach to Health Behaviour Change Patient Education Patient

4. Summary of Research on Health Behaviour Change Traditional strategies for increasing motivation (e.g. fear induction, education, threats, directive methods) create reactance and resistanceTraditional strategies for increasing motivation (e.g. fear induction, education, threats, directive methods) create reactance and resistance Place patient in passive rolePlace patient in passive role Risk appraisalRisk appraisal Problem behaviours are hard to change regardless of motivationProblem behaviours are hard to change regardless of motivation People who change move through stagesPeople who change move through stages Permanent change usually requires several attemptsPermanent change usually requires several attempts

5. Understanding Behaviour Change What is motivation ? Ready, willing & ableWhat is motivation ? Ready, willing & able –Willing Desire or will for change; perceived importanceDesire or will for change; perceived importance Discrepancy between status & goal; self-regulationDiscrepancy between status & goal; self-regulation Low Importance pathological ?Low Importance pathological ? – Able Confidence for change; self-efficacyConfidence for change; self-efficacy Defenses against failureDefenses against failure –Ready Is change a priority now?Is change a priority now?

6. Understanding Behaviour Change What triggers change?What triggers change? – Avoidance of discomfort ? –Change & Intrinsic motivation Connection to cherished valuesConnection to cherished values Arises in an accepting, empowering atmosphereArises in an accepting, empowering atmosphere Arises from exploration of ambivalenceArises from exploration of ambivalence

7. Understanding Behaviour Change What is ambivalence ?What is ambivalence ? –Feeling two ways: I want to but I don’t want to Addiction, Infidelity, SmokingAddiction, Infidelity, Smoking –Pathology or Human Nature? –Ambivalence: A phase in the process of change

8. What is my role as a health professional ? Behaviour change agent ?Behaviour change agent ? “Fix-it” role“Fix-it” role –Provide advice, direction, education whether patient is ready or not –Practitioner centered –Patient in passive stance Motivational RoleMotivational Role –Focus on benefits, risks –Give advice if requested –Relate in flexible ways –Client centered, client an active participant

9. Promoting Behaviour Change Value BaseValue Base –Respect for Patient Autonomy SkillsSkills –Confrontational interviewing style can be unproductive –Information exchange is a critical skill – Readiness to change should be monitored –Assess importance and confidence Roles - Practitioner –Provide structure, direction, support –Provides information wanted by the patient –Elicits and respects patients views –Negotiates change sensitively Roles - Patient –Is an active decision- maker

10. Enhancing Motivation Establish Rapport Set Agenda Assess Importance and Confidence Single Behaviour Multiple Behaviours Build Confidence Explore Importance Exchange Information Reduce Resistance

11. Thomas, 1970 Active Listening Patient Clinician What the Patient means means What the Clinician Understands 1 2 3 What the Patient says What the Clinician hears

12. Establish Rapport Take your timeTake your time Preparation for discussion of behaviour changePreparation for discussion of behaviour change Prior relationship vs. New consultPrior relationship vs. New consult Physical settingPhysical setting Patient thoughts and feelingsPatient thoughts and feelings Strategy: A typical dayStrategy: A typical day

13. Setting Agenda Ask permission to raise the issueAsk permission to raise the issue –“Would it be okay if you and I talked a bit about your progress in treating your high BP?” Neutral Information ExchangeNeutral Information Exchange –Elicit – Provide – Elicit “How concerned are you about your blood pressure levels”“How concerned are you about your blood pressure levels” “We know that exercise helps lower your blood pressure.”“We know that exercise helps lower your blood pressure.” “What do you think of that?”“What do you think of that?”

14. Assess Importance & Confidence Informal AssessmentInformal Assessment –Open-ended questions –Elicit patient thoughts about value of change & obstacles to it Formal AssessmentFormal Assessment –Use ratings or ruler “How important is it, at this moment, for you to get better control over your BP ?”“How important is it, at this moment, for you to get better control over your BP ?” “How confident do you feel about increasing your activity level?”“How confident do you feel about increasing your activity level?”

15. Explore Importance & Confidence ImportanceImportance “What would have to happen for your smoking to become much more important for you to change?”“What would have to happen for your smoking to become much more important for you to change?” “Why is your importance score 6 and not 0?” “What are things you like (and dislike) about you’re your alcohol use?”“Why is your importance score 6 and not 0?” “What are things you like (and dislike) about you’re your alcohol use?” “What would need to change for your Importance score to move from 5 to 9?”“What would need to change for your Importance score to move from 5 to 9?” ConfidenceConfidence “What would make you more confident about succeeding in losing weight?”“What would make you more confident about succeeding in losing weight?” “What have you found helpful when you succeeded in hard tasks in the past?”“What have you found helpful when you succeeded in hard tasks in the past?”

16. Exploring Importance & Confidence “How do you feel about your progress so far?”“How do you feel about your progress so far?” “How concerned are you about your smoking?”“How concerned are you about your smoking?” “What do you think you need to do in order to get better ?”“What do you think you need to do in order to get better ?” “How confident are you that you could quit smoking if you put your mind to it?”“How confident are you that you could quit smoking if you put your mind to it?”

17. Reduce Resistance What is it ?What is it ? What Causes it ?What Causes it ? Avoiding resistance trapsAvoiding resistance traps –Take control away –Misjudge importance, confidence, readiness –Meet force with force Dealing with resistanceDealing with resistance –Emphasize personal choice & control –Reassess readiness, importance and confidence –Back off and come alongside the patient