1. Counseling for Behavior Change F. Daniel Duffy, MD, MACP Michael G. Goldstein, MD © 2000 ACP

2. Objectives 1. Background 2. Counseling Steps 1. Preparation 2. Determination to Action 3. Maintaining Change

3. Background 4 Cycle of Change 4 Brief Intervention FRAMES 4 Reflective Listening

4. Stages of Change Cycle Precontemplation Contemplation Determination Action Maintenance Relapse

5. Implications of Change Cycle u Majority are NOT ready for action u Each cycle improves the chance of maintenance of long-term change u Counseling that is matched to stage enhances outcome u Relapse is common and is a learning stage

6. Brief Intervention Features F Personalized Feedback to patient R Patient has Responsibility for change A Clear Advice on behavior to change M Menu of options for choice E Express Empathy to mobilize change S Evoke Self-efficacy to enhance confidence

7. Reflective Listening u Empathy u Legitimize u Respect u Support u Partnership u Optimism

8. Counseling Step # 1 Preparation 4 Delivering the Message 4 Precontemplation 4 Contemplation

9. The Message Counseling u Give Personalized Feedback –Clear message, advice to change –Shutdown –Doctor babble u Determine Readiness to Change (Stage) –Ask - “What do you KNOW about this?” –Ask - “How do you FEEL about this?” –Ask - “What are you willing to DO about this?”

10. Pre-Contemplation Clues u Surprise u Ignorance u Demoralization

11. Pre-Contemplation Counseling u Give information u Patient education works u Logbooks, journals, self-assessment u Classes u Role-models

12. Contemplation - Clues u Ambivalence u Emotional arousal u Defensiveness u Resistance u Self-re-evaluation u Values - behavior gap

13. Contemplation - Counseling u Express Empathy u Develop Discrepancy u Avoid Argument u Roll with Resistance u Support Self-efficacy u Use Decision Balance

14. Decision Balance Exercise

15. Counseling Step #2 Determination to Action 4 Determination Stage 4 Self-Efficacy - Play Hard To Get 4 Action Plan 4 Action Plan Interview 4 Action Stage

16. Determination u Ephemeral stage u Must do something about the problem u Build Self-efficacy –Skills –Confidence of success –Conviction to act u Develop plan for action

17. Determination Clues u “This is a serious problem” u “I must do something!” u “I can make the change” u NOT “What do you recommend I do?” u NOT “Whatever you say I’ll do!”

18. Determination Counseling Play “hard to get” in telling what to do –“Only you know what is best for you. This is what others have used” –“I’m not sure you’re ready to act yet; convince me” –“How convinced are you change will help?” –“How confident are you you’re change will be successful?”

19. Plan for Action u Realistic goal u Small steps u Short trial period (7 days) u Self-monitoring u Role-models u Go public u Plan for problems and lapses

20. Building an Action Plan u Here is a MENU of options… u What are you willing to DO? u What or who might HELP? u What PROBLEMS might arise? u What will you DO until we next meet?

21. Action u Patient makes changes alone u Withdrawal symptoms – physical withdrawal – psychological withdrawal u New coping behaviors u Clues to act and avoid old habit u Clues and rewards for new behavior

22. Action Counseling u Moral support u Log or journal u Role-model u Frequent contact u Treat withdrawal symptoms u Devise diversions

23. Counseling Step #3 Maintaining Change 4 Maintenance 4 Behavior Modification 4 Social Support - Role-Models 4 Relapse Learning 4 Follow-up

24. Maintenance Clues u Humility u Humor u Honesty u Experience u Success and failure u Respect for conditions of relapse

25. Maintenance Counseling u Self-monitoring u Attend to cues and consequences of new and old behavior - act to form new habit u Address maladaptive thoughts u New coping strategies for H.A.L.T. u Use and become a role-model

26. Relapse u Common, may be necessary u Reframe as a learning experience u Experience loss of control u Learn pre-relapse clues u Experience “relapse” thinking u Cope with guilt and shame u Cope with guilt and shame, “I blew it!”

27. Relapse Counseling u Express empathy for guilt, shame, distress u Confront “stinking thinking” u Explore triggers to relapse u Plan for different coping strategies u Negotiate a new action plan u Consider referral or increasing intensity of support u Role-models u Close follow-up

28. Summary u Deliver a clear message about change u Counsel by asking not telling u Determine patient’s stage or change u Use stage-specific counseling u Use brief intervention methods u Change involves more than knowledge u Relapse is a usual stage of change