Motivating Change Participant Manual
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© 2017, The Permanente Medical Group, Inc. All rights reserved. Contents What Is Motivating Change?...... 2 Goals of Motivating Change...... 3 Motivating Change Pyramid...... 4 Clinician Style and Behavior Change...... 5 Clinician Style ...... 6 Characteristics of Clinician Style ...... 7 How to Express My Style?...... 8 Sustain Talk ...... 9 Change Talk...... 10 Clinician Style...... 12 Motivating Change Skills: Ask, Listen, Summarize...... 13 Ask Open-Ended Questions...... 15 Listen ...... 16 Roadblocks to Effective Listening...... 18 Summarize...... 19 Reflective Listening ...... 21 Reflective Listening ...... 22 Levels of Reflection ...... 24 Reflective Listening ...... 25 Reflecting Emotions...... 26 Information Exchange...... 27 Providing Education: Less Is More...... 28 Sharing Clinical Information: Neutrality Is Key...... 29 Offering Advice: Collaboration Is Essential...... 30 Expressing Confidence: Perception Is Powerful ...... 31 Follow the Roadmap...... 33 About the Roadmap...... 34 Motivating Change Roadmap ...... 35 Open and Engage...... 37 Negotiate the Focus...... 39 Assess Readiness...... 41 Tailor the Transition: The Patient Who Is Unsure...... 43 Tailor the Transition: The Patient Who Is Not Ready...... 45 Tailor the Transition: The Patient Who Is Ready...... 49 Close the Encounter ...... 52 Developing Competency in Motivating Change...... 55 Patients as Teachers...... 57 Open the Encounter ...... 58 Negotiate the Focus...... 59 Assess Readiness...... 60 Working with the Patient Who Is Unsure...... 61 Working with the Patient Who Is Not Ready...... 62 Close the Encounter ...... 63 Provide Education ...... 64 Share Clinical Results...... 65 Advice, Choice, and Confidence...... 68 Observer Worksheet...... 70 Motivating Change History, Theory, and References...... 73 Motivating Change History...... 74 Theory ...... 77 Stages of Change...... 79 References...... 80 Acknowledgments...... 86 HeadingWhat Is Motivating Change?
• A collaborative counseling style designed to enhance patients’ internal motivation to make health behavior change • Based on established behavior change theory and empirical clinical research • Client-centered and directive • Effective in brief clinical encounters • An empathic, accepting, and eliciting approach • Effective across a broad range of patient concerns, diagnoses, and clinical settings • The identified standard of practice for health behavior change counseling in the Kaiser Permanente Northern California Region • Endorsed as a Successful Practice by Kaiser Permanente’s Care Management Institute
FUNDAMENTAL BELIEF The potential for making health behavior change is within every person.
2 CLINICIAN STYLE AND BEHAVIOR CHANGE Goals of Motivating Change
Engage and Establish Rapport Positive rapport creates a climate for honest and constructive discussions about health behaviors.
Focus the Encounter Many patients are faced with multiple behavior changes that impact their well-being. Negotiating a focus for the encounter makes addressing change more manageable and more likely to succeed.
Elicit “Change Talk” People are more powerfully influenced by what they hear themselves say than by what someone else tells them. Motivation can be substantially increased when patients have the opportunity to verbalize their own desire and reasons for making a change.
Listen Listen actively with empathy and compassion. Pay attention to words, body language, nuance, and silence. Check in frequently for understanding by using summary and reflection.
Assess Readiness Assessing readiness helps both the patient and the clinician better understand the patient’s current level of motivation for change.
Tailor Your Approach Matching clinician approaches and strategies to the patient’s stage of readiness can help evoke change talk and build motivation.
Emphasize Choice Behavior change is the patient’s responsibility and choice. Communicating acceptance of patient’s level of readiness allows them to move more readily toward positive health behaviors.
Advise, Inform, and Educate Sharing education, clinical results, and professional advice in a collaborative and respectful manner supports patient motivation.
Express Empathy and Confidence An empathic style and a clinician’s confidence in the patient’s ability to change have been shown to improve patient outcomes.
CLINICIAN STYLE AND BEHAVIOR CHANGE 3 HeadingMotivating Change Pyramid
Tools • Road Map • Ruler • Options Tool
Skills • Ask Open-Ended Questions • Listen • Summarize
Clinician Style • Empathic • Accepting • Supportive of Self-Efficacy • Collaborative • Compassionate
4 CLINICIAN STYLE AND BEHAVIOR CHANGE Clinician Style and Behavior Change HeadingClinician Style
Motivation and resistance are often direct products of the interpersonal interaction between patient and clinician. Research indicates that clinician style exerts a powerful influence on both motivation for change and resistance to change.
(Miller & Baca 1983; Miller et al., 1993)
6 CLINICIAN STYLE AND BEHAVIOR CHANGE Characteristics of Clinician Style
The following style characteristics support patients to consider behavior change:
Empathic
Nonjudgmental Collaborative
Affirming People don’t Gentle care how much you know until they know how much you care. Eliciting Accepting JOHN HANLEY
Respectful Curious
Compassionate
CLINICIAN STYLE AND BEHAVIOR CHANGE 7 How to Express My Style?
Empathy The clinician who expresses empathy:
• Listens attentively and respectfully, offering thoughtful summaries and reflections. • Responds in a genuine and congruent manner with a focus on the patient’s experience and interpretation. • Cultivates an awareness of verbal and nonverbal cues that reveal the emotional as well as the factual content of the patient’s narrative. The empathic clinician then uses the information gleaned from these cues to assist patients to reach a deeper understanding of the issue.
Acceptance The clinician can accept a particular behavior or point of view without condoning or agreeing with it. The accepting clinician:
• Communicates a sincere desire to understand the patient’s perspective. • Develops the ability to set personal judgments aside and communicate an open and neutral stance. • Recognizes that low motivation, indecision, and relapse do not represent pathology. The accepting clinician helps the patient to normalize these states as a natural part of the change process and uses Brief Negotiation skills and style to help the patient move forward.
Collaboration The collaborative clinician:
• Engages the patient as a coprovider by eliciting the patient’s point of view and supporting personal choice. • Strikes a respectful balance between directive and patient-centered approaches. • Tailors responses to the patient’s unique circumstances, abilities, and resources.
Support of Self-Efficacy The clinician who effectively supports patient self-efficacy:
• Affirms the patient’s positive efforts and health behaviors. • Helps patients create realistic action plans focusing on small, achievable steps that enable the patient to build on their successes. • Expresses confidence in patients' abilities to make a change when they are ready to do so.
8 CLINICIAN STYLE AND BEHAVIOR CHANGE Sustain Talk
Recognizing Sustain Talk Sustain talk can be viewed as any expression that supports the status quo or moves away from the direction of the health behavior under discussion. Sustain talk statements include:
• Arguing in favor of the status quo or expressing reasons not to change • Blaming others for current behavior or perceived inability to change • Excusing or minimizing the risks of current behavior • Ignoring or declining to engage in conversation about the issue at hand • Challenging the accuracy of information or validity of suggestions • Expressing pessimism or lack of confidence about making a change
Examples of Sustain Talk • Yes, but… • I’m not all that overweight. • My grandpa smoked for 50 years and he lived to be 92. Why should I quit? • If I don’t drink, I can’t stand my job and my family drives me crazy. • I don’t need any medicine for that. I read online that the normal range for that test is way higher than you say.
Importance of Sustain Talk When you hear sustain talk, it’s a cue to clinicians to examine their style. Is the clinician arguing for the change, criticizing, blaming or labeling the patient? Also, sustain talk is a signal the patient may not be ready to make a change.
Navigating Sustain Talk • Use reflective listening to acknowledge the patient’s perspective • Emphasize personal choice • Communicate nonjudgment and empathy • Shift the focus of the encounter • Reframe the issue: Validate the patient’s perspective and offer an alternative view
CLINICIAN STYLE AND BEHAVIOR CHANGE 9 HeadingChange Talk
Recognizing Change Talk Change talk is any language that the patient says as an argument for change. The patient’s statements will fall into 2 categories, using the acronym DARN CATS (Miller and Rollnick, 2013).
Preparatory change talk indicates early change language: Desire (for change) Ability (to make change) Reasons (to make change) Need (for change)
Mobilizing change talk indicates the person is closer to making a change: Commitment (to change) Activation (leaning toward taking action) Taking Steps (toward change)
Examples of Change Talk • I really want to get my blood sugar under better control. Paying more attention to my diet should help. (Desire) • I’ve walked in the past and I know I can do it. (Ability) • If I don’t start taking my medicine regularly, I’m going to wind up in the emergency room again. I really don’t want that to happen. (Reasons) • I think cutting back on alcohol would help me feel better. (Reasons) • I need to sleep more. I’m falling asleep in the middle of my day. (Need) • I will quit smoking to set an example for my children. (Commitment) • Once I sit down tonight and make myself a specific schedule, I’ll be able to keep up with regular exercise. (Taking Steps)
Importance of Change Talk When patients verbalize their motivation for change they are more likely to attempt and to succeed in making behavior change (Miller & Rollnick, 2002). Therefore, a central goal of any conversation about behavior change is to elicit change talk. We know that people are more strongly influenced by what they hear themselves say than by what others tell them (Bem, 1972). Our primary aim as clinicians is to assist our patients to talk themselves into making a positive change.
10 CLINICIAN STYLE AND BEHAVIOR CHANGE Change Talk
Eliciting Change Talk Patients often feel a wide range of readiness and ambivalence (feeling 2 ways) toward making behavior changes. Guide the conversation toward change by using a neutral, curious style to elicit change talk. Ask strategic open-ended questions to elicit change language, then reflect the participants’ change talk back so they can hear their own argument for change.
Tips for Success • Communicate a nonjudgmental and empathic stance • Ask strategic open-ended questions, for example: • How might your life be different if you made this change? (Desire) • Tell me what you want to be different in the future. (Desire) • If you decide to do this, how might you go about it? (Ability) • What are your ideas for how you could make this change? (Ability) • What are some reasons for you to consider this change? (Reasons) • What would be some advantages of making this change? (Reasons) • Why is this change important to you now? (Need) • What needs to happen for you to do this? (Need) • Use the scaling questions on the ruler: Why a 6? / Why a 6 and not a 3? / What would it take to move you up the scale? • Use reflective listening to encourage patients to continue to talk about and explore their issues / attitudes / plans / concerns • Invite the patient to elaborate on change talk by asking, “What else?” • Allow silence: Give patients time to think and consider on a deep level and then to express their insights
CLINICIAN STYLE AND BEHAVIOR CHANGE 11 Clinician Style
Research shows that a clinician’s style exerts a powerful influence on a patient’s motivation for change. When a clinician uses a guiding, collaborative style, it creates safety for a person to consider change and ultimately choose if and when they make a change. When a clinician uses a directing style and argues for change with a person who is ambivalent, it naturally brings out the person’s arguments against change (Miller & Rollnick, 2013)
Clinician style that enhances motivation to change • Empathic • Nonjudgmental • Curious • Genuine interest • Quiet, eliciting stance • Respectful • Collaborative • Emphasis on choice
Clinician style that decreases motivation to change • Coercing, arguing, imposing • Blaming, shaming, criticizing • Judging, labeling, warning • Commanding, threatening • Moralizing, preaching, lecturing • Assuming the expert role • Overriding the patient’s agenda with your own
12 CLINICIAN STYLE AND BEHAVIOR CHANGE Motivating Change Skills: Ask, Listen, Summarize Motivating Change Skills
Asking open-ended questions, listening, and summarizing are core skills of motivating change. These are the skills that provide a vehicle for expressing a collaborative, supportive style, and creating direction in the clinical encounter.
14 MOTIVATING CHANGE SKILLS: ASK, LISTEN, SUMMARIZE Ask Open-Ended Questions
Goals • Engage the patient as an active participant in the encounter • Gather pertinent information • Explore ambivalence • Elicit change talk • Explore ideas and options Key Elements • Be deliberate and strategic in using open-ended questions. • Consider the information you’d like to elicit from the patient, then formulate a question that is likely to bring forth the information. • Ask open-ended questions that encourage patients to explore issues and build motivation. These might include those designed to elicit: • Recognition of an issue • Current behaviors • Recent efforts to make change The key • Confidence in ability to change to solving • Concerns about a perceived problem any problem is • Ideas and options for change • Reasons and arguments for change asking the right • Roadblocks to making a change questions.
• Intentions for change ALBERT EINSTEIN Examples • What have you been doing so far to manage your cholesterol? • What might help to succeed with your plan? • What are your reasons for wanting to begin exercising? • What would need to be different for you to quit smoking? • What are some of the things you hope to change about current eating habits? • How might your life be different if you make this change? • How does smoking fit into your life? • You mentioned that you are concerned about your drinking. Tell me more about your concerns.
MOTIVATING CHANGE SKILLS: ASK, LISTEN, SUMMARIZE 15 Listen
Goals • Build and maintain positive rapport • Create a supportive environment for the patient to think and talk about change (change talk) • Demonstrate that you value and accept the patient’s perspective • Create an opportunity for the patient to explore an issue deeply • Tap into the patient’s natural change potential Key Elements Nonverbal • Establish comfortable and culturally appropriate eye contact What people • Ensure that your posture and facial expressions really need is a communicate a relaxed, attentive, receptive, and nonjudgmental attitude good listening to.
• Use natural gestures MARY LOU CASEY • Listen without interruption • Allow silence: Patients often need a few moments to access, understand, and verbalize their thoughts and feelings
Verbal • Speak in warm, pleasant tones • Vary your rate of speech: Avoid monotony • Pay attention to talk time: Encourage the patient to do most of the talking • Use minimal encouragers: • Mm hmm • Go on ... • For instance … • Really? • I see • And? • Tell me more • What else? • Paraphrase and reflect the patient’s ideas and feelings: • You think ... • You feel ... • It sounds like you ... • You’re wondering if ... • It seems to you that ... • It’s hard for you to imagine ... • So you ... • You’re feeling ...
16 MOTIVATING CHANGE SKILLS: ASK, LISTEN, SUMMARIZE Listen
Beyond Words • Active listening is the gateway to understanding and meaningful communication • The quality of your listening has a profound impact on your patient’s likelihood to consider health behavior change and to accept information and advice • Listen openly, setting aside your judgment and your personal story • Pay attention to your patient’s choice of words, tone, inflection, gestures, body language, pacing • Listen for the emotion and nuance underlying the words • Bring compassion, empathy, and receptivity to the foreground of your awareness • Listen with a genuine desire to understand the patient’s perspective
You
Ears Eyes
Undivided Attention
Heart
Consider the Chinese symbol for the verb to listen as a reminder of the complexity of empathic listening. The symbol is comprised of four elements: ears, eyes, heart, and undivided attention. These are resources we all possess and can further develop in order to become artful and effective listeners.
MOTIVATING CHANGE SKILLS: ASK, LISTEN, SUMMARIZE 17 Roadblocks to Effective Listening
• Ordering, directing, or commanding • Warning, cautioning, or threatening • Giving advice, making suggestions, or providing solutions • Persuading with logic, arguing, or lecturing • Moralizing, preaching, or telling patients what they “should” do • Disagreeing, judging, criticizing, or blaming • Agreeing, approving, or praising • Shaming, ridiculing, or labeling • Interpreting or analyzing • Reassuring, sympathizing, or consoling • Questioning or probing • Withdrawing, distracting, humoring, or changing the subject
From Thomas Gordon’s Parent Effectiveness Training, 1970
18 MOTIVATING CHANGE SKILLS: ASK, LISTEN, SUMMARIZE Summarize
Goals • Show that you have been listening • Clarify understanding • Provide a mirror to reflect the patient’s perspective and change talk • Reinforce what has been said and highlight major themes of the conversation • Provide a transition to the next topic or bring closure to a conversation Key elements • Summarize in a concise manner • Preface a summary statement with an introduction • Let me see if I understand what you’ve told me so far ... • Before we move on, I’d like to capture what you’ve said so far ... • What I understand you are saying is ... • Our time is almost up. Let’s take a look at what you’ve worked through today ... • If a patient has expressed ambivalence, it is useful to capture both sides of the ambivalence • On the one hand ... on the other hand ... • You feel ... and at the same time you are concerned about ... • When summarizing ambivalence, begin with the statements that support the status quo and end with the statements that encourage movement toward change • End a summary statement with an invitation for the patient to respond • How did I do? • What have I missed? • Did I get it all? Avoid • Lengthy or rambling summary • Adding your own interpretation
MOTIVATING CHANGE SKILLS: ASK, LISTEN, SUMMARIZE 19
Reflective Listening Reflective Listening
Reflective listening is a sophisticated skill that serves to move an encounter forward by eliciting change talk, clarifying meaning, and encouraging exploration of an issue.
The words the The words the speaker states listener hears
What the What the REFLECTIVE LISTENING listener thinks the speaker means speaker means
Reflective listening is a way to check whether what the speaker means and what the listener understands are the same.
Communication can be derailed when:
1. The speaker does not say exactly what is meant
2. The listener does not hear the words correctly
3. The listener interprets the words differently than the speaker had intended
22 REFLECTIVE LISTENING Reflective Listening
Reflective listening is a form of hypothesis testing. It is a way to check in with patients to see whether you understand what they are saying and feeling.
Although it represents a hypothesis, reflective listening is offered in the form of a statement rather than a question. Repeated questioning, even open-ended questions can evoke resistance or create distance between the clinician and the patient. A well-constructed reflection is less apt to elicit resistance than a series of questions, and can serve to move the conversation forward.
A “rule of thumb” cited by researchers analyzing motivational interviewing is that a proficient clinician will generally offer 2 or 3 reflections for every open-ended question asked (Miller & Rollnick, 2002).
Goals • Encourage the patient to explore and analyze thoughts, feelings, and insights • Amplify understanding of the patient’s perspective • Elicit and mirror change talk • Gently and deliberately direct the encounter Effective openings for reflective statements The greatest • You feel ... motivational act • You’re wondering whether ... one person can • It seems to you that ... do for another • You imagine that ... • It’s confusing to think that ... is to LISTEN. • You’re concerned that ... ROY E. MOODY • You’d like to see ...
Thinking Reflectively Learn to think reflectively by listening attentively to your patients, then asking yourself, “Does the patient mean ... ?” Consider the possible meanings and formulate a statement of the meaning you feel is most likely. Remember that your intention is not to be a mind-reader or to tell patients what they ought to be thinking. Rather, you are testing your understanding. Your tone of voice and demeanor are gentle, curious, and eliciting.
REFLECTIVE LISTENING 23 Levels of Reflection
Simple Reflection Repeating: Repeats an element of what was said. Sometimes a single word or phrase is enough to encourage the patient to continue to explore.
Patient: Sometimes I feel like I take too much pain medicine, that it might be hurting me in the long run.
Clinician: Too much ...
Patient: Yes, for example last week ...
Rephrasing: Rewords what was heard without interpretation.
Patient: Even growing up, I didn’t like sports and all that. I liked to read and tinker with machines.
Clinician: You’ve never really liked exercise.
Patient: Right. And I know exercise would help bring my blood sugar down.
Deeper Reflection Paraphrasing: Infers meaning, reflects in new words.
Patient: I know smoking isn’t good for my baby.
Clinician: You want to be a good mom.
Patient: Yes, I do… I just don’t know if I can quit.
Reflection of Feeling: Emphasizes the emotional content of the patient’s narrative.
Patient: I’m having trouble with my memory lately. It’s pretty weird to call someone on the phone at work and not remember why you called — that’s happened to me a few times just this week.
Clinician: It’s worrisome to think that drinking could be affecting your memory.
Patient: Yeah, I guess I am a little worried. I don’t want to lose my job.
24 REFLECTIVE LISTENING Reflective Listening
Understate versus Overstate When reflecting feeling, it is recommended to understate rather than overstate the emotion. Overstating the emotion can cause the patient to minimize or defend an unhealthy behavior. Consider this example of overstatement using the previous scenario.
Patient: I’m having trouble with my memory lately. It’s pretty weird to call someone on the phone at work and not remember why you called. That’s happened to me a few times just this week.
Clinician: It’s terrifying to think that drinking could be affecting your memory.
Patient: Well, I wouldn’t say that. I’m just getting a little forgetful.
Continuing the Paragraph Another way to think of deeper reflections is listening carefully to what the patient says and then offering the next sentence. These types of reflections tend to create momentum in the interaction and encourage the patient to further examine the issue.
Patient: I know smoking could get me in the long run.
Clinician: And that concerns you.
Patient: Yeah, it does. I mean, I really have no one to blame but myself if this makes me sick. You know, like getting cancer or emphysema or something.
Metaphor and Simile Metaphors and similes can also serve as effective reflections by creating vivid images for the patient.
Patient: I just don’t know where to go from here. It’s hard to know what will happen with either choice.
Clinician: It’s like being in the wilderness without a map or compass.
Patient: Yeah, I guess I do feel a little lost.
Clinician: What might help you find your way?
REFLECTIVE LISTENING 25 Reflecting Emotions
Understate versus Overstate
STRONG
HAPPINESS ANGER SADNESS
delirious enraged despondent
overjoyed incensed joyless
delighted furious miserable
tickled irate depressed
cheery mad gloomy
chipper angry blue
happy sore downhearted
glad irked low
pleased bothered down
content irritated unhappy
okay annoyed
MILD
26 REFLECTIVE LISTENING Information Exchange Providing Education: Less Is More
Goal Offer supportive education in a manner that is useful to patients in their self-management efforts.
Provide education when: • You ask (and receive!) permission or • Your assessment / conversation with the patient reveals a knowledge deficit or misunderstanding or • The patient asks for information
Key Elements • Assess the patient’s current knowledge: What are you doing now to control your blood sugar? What kinds of things do you think can improve your blood pressure? • Build on what the patient already knows • Keep the education simple, strategic, and succinct: Nearly half the US population has low or marginal literacy. Use plain language and simple visuals. Repeat key messages and focus on specific actions to improve outcomes. • Focus on a few key points in each encounter • Use audiovisual and written materials as appropriate to enhance learning and retention • Check in frequently for patient understanding: So I know I’ve explained how to take your medicine, please tell me how you’ll take your pills tomorrow. • If appropriate, ask for return demonstration
Avoid • Assumptions about the patient’s current knowledge level • Overwhelming the patient with too much information • Offering pamphlets, articles, health education information the patient does not want
28 INFORMATION EXCHANGE Sharing Clinical Information: Neutrality Is Key
Goals • Offer lab results, behavior indicators, and other clinical measures to the patient in a neutral manner • Provide pertinent data to assist patients with decision-making and behavior change
Key Elements • Ask permission • Check patient’s understanding of the test and provide a brief explanation if needed • Compare results to standards / goals • Ask for the patient’s interpretation • Offer your interpretation or advice as needed AFTER eliciting the patient’s response • Emphasize the positive
Example Clinician: Mr. Jones, I have your recent HgA1C test results. Would you be interested in looking at it together? Patient: Sure. Clinician: What is your understanding of this test? Patient: Well, I think you said before that it shows generally how my sugar control has been over the last 3 months. Clinician: That’s correct. And we know that people who keep their HgA1C below 7% have fewer complications from their diabetes. Your result from last week was 8.3%. The target for this test is less than 7%. What do you think of these results? Patient: Well shoot, it’s still way too high. Clinician: It is still higher than we recommend. Still, you’ve come down quite a bit. Your test from last time was 8.8%. I want to congratulate you on your success in bringing this measure closer to goal. The good news is, there are a number of things we can talk about that can help you reach even better control.
Avoid • Judging or labeling the patient based on the results • Insinuating that the patient must do something about the issue • Offering your interpretation before eliciting the patient’s reaction • Using clinical information to coerce, manipulate, or shame
INFORMATION EXCHANGE 29 Offering Advice: Collaboration Is Essential
Goal Offer your professional perspective in a manner that encourages patients to be open to hearing your advice and taking it to heart.
Offer advice when: • The patient asks for your advice or • You ask (and receive!) permission or • You feel professionally obligated to give advice
Key Elements • Keep your advice clear and succinct • Emphasize the patient’s personal choice to follow your advice • Express confidence in the patient’s ability to make a change if they decide to do so • Elicit the patient’s response as appropriate
Example As your clinician, I strongly encourage you to quit smoking. From my perspective, it is the single most important thing you can do for your health. I also recognize that the decision to quit is entirely yours, and I’m confident if you decide to quit, you'll find a method that works best for you. We have a number of programs at Kaiser Permanente to help. Feel free to call or come in any time you would like further information or assistance in quitting smoking.
Avoid • Telling the patient what to do and when to do it • Overusing this strategy • Judging, shaming, circumventing the issue
Advice Choice Confidence
30 INFORMATION EXCHANGE Expressing Confidence: Perception Is Powerful
Goal Express your confidence in patients as a way to enhance their motivation and the likelihood of Clinician successful behavior change. confidence can contribute significantly Key Elements to a patient’s success • Confidence statements reflect the knowledge in making health that people will find a way to change when they are ready and committed to do so behavior change. • People are more likely to change when they LEAKE & KING are confident they are capable of making the change • Effective confidence statements are succinct, genuine, realistic, and supportive of self-efficacy • Express confidence in the person’s potential for making a health behavior change
Examples • I am confident that if you decide to begin on a regular basis, you can develop a plan that works for you. • I feel certain that if you choose to you can find a way to make it happen. • From our conversation today, it is clear to me that if you decide to you can create a plan that is effective for you. • I am confident that your [enthusiasm, determination, success with other lifestyle changes] will be of great value as you begin to work on this plan. • I feel very positive that if you choose to you can formulate a strategy that is practical for you.
Avoid • Promoting unachievable or unrealistic expectations • Embedding a judgment, such as confidence that a client will make the “right” choice • Promoting your agenda without regard for the client’s expressed goals • Offering an expression that is not genuine
INFORMATION EXCHANGE 31
Follow the Roadmap About the Roadmap
The motivating change roadmap is a guideline comprised of a number of elements that are effective for working with patients toward health behavior change. It is a snapshot of one way you might construct a health care encounter. While it is often helpful to step through the roadmap systematically when first learning, it is not meant as a rigid template.
In your practice, no two encounters will be alike. Sometimes you will use a few elements of the roadmap; other times you might use all of it. Sometimes it may not seem appropriate to use it at all. As you practice the method over time, you’ll discover how best to incorporate it into your personal style and area of practice. When you develop proficiency with the skills and style of motivating change, your use of the method will become more fluid and artful.
34 FOLLOW THE ROADMAP Motivating Change Roadmap
1 Open and Engage 2 Negotiate the Focus • Introduce yourself and your role • Offer options: On this chart are a number • Offer appreciation of things that can affect . • Confirm the reason for the visit • Elicit patient choice: Is there one area you would like to focus on today? Is there something you’d • State the appointment length like to add to the chart, or something else you’d • Ask permission to discuss topic rather talk about? • Ask strength-based open-ended question • Evoke change talk: What are some reasons Example: What have you done in the to consider making this change now? past to manage [X]? • Listen / reflect change talk • Listen without judgment or interruption • Information exchange as appropriate • Summarize / reflect change talk • Information exchange as appropriate
NOT READY READY 3 Assess Readiness • Ruler or Readiness Scale 0–10 021 345 678910 • Straight question: Tell me about a 5? • Backward question: Why a 5 and not a 2? (move down 1 or 2) • Forward question: What would need to be different to move from a 5 to a 7 or 8? (move up 1 or 2) • Listen for change talk. Summarize
4 Tailor the Transition Not Ready (0–3) • What might need to happen for you to consider ? • Raise Awareness • Would you be interested in knowing more about ? • Elicit Change Talk • What kind of follow-up or resources would be helpful for you? • Advise & Encourage • Reflect change talk, and summarize as appropriate. Unsure (4–6) • What do you see as your next steps? • Resolve Ambivalence • What are you thinking / feeling at this point? • Elicit Change Talk • Where does fit into your future? • Build Readiness • Reflect change talk, and summarize as appropriate. Ready (7–10) • What are your ideas for ? / How might you do it? • Strengthen • How might your life be different when you make this change? Commitment • What barriers might you encounter when making this change? • Elicit Change Talk • How might you work around the barriers? • Negotiate Plan • Reflect change talk, and summarize as appropriate.
5 Close the Encounter • Show appreciation • Offer advice if appropriate • Affirm positive behaviors • Emphasize choice • Respectfully acknowledge decisions • Express confidence • Arrange for follow-up as appropriate and link with available resources
FOLLOW THE ROADMAP 35 Motivating Change Roadmap
Information Exchange Empathic • Supportive of Self-Efficacy • Nonjudgmental • Collaborative • Clear and Succinct
Providing Education Sharing Clinical Results • Ask permission • Ask permission • Assess current knowledge • Check patient’s understanding of the test • Avoid overwhelming patient with too • Compare results to norms much information • Ask for patient’s interpretation • Check in frequently for Sample: “Your tests results are . understanding The standard for this test is . • Ask for return demonstration What do you make of this information?” Offering Advice Sample Advice Statement: Give advice only if: “As your health care provider, I strongly encourage you to • Patient asks quit smoking. From my perspective, this is the single most important thing you can do for your health. Of course, • You ask permission deciding to quit is your choice. I am confident that if you • You are professionally bound decide to quit, you will find the method that works best for you.”
Confidence Statement Genuine • Succinct • Realistic • Supportive of Self-Efficacy Confidence statements are based on the knowledge that: 1) All people have the capacity to make health behavior change; and 2) When they are truly ready to change, they will find a way.
Caution! Avoid the following: • Promoting unachievable or unrealistic expectations • Embedding a judgment, such as confidence that a client will make the “right” choice • Promoting the clinician’s agenda without regard for the client’s expressed goals • Offering an expression that is not genuine
Sample Confidence Statements • I am confident that should you decide to begin on a regular basis, you will develop a plan that works for you. • I feel certain that if you choose to you will find a way to make it happen. • From our conversation today, it is clear to me that if you decide to you will be able to create an approach that is effective for you. • I am confident that your [enthusiasm, determination, success with other lifestyle changes] will be of great value as you begin to work on this plan. • I feel very positive that if you choose to , you will find a strategy that is doable for you.
36 FOLLOW THE ROADMAP Open and Engage
Overview The foundation for productive discussion about health behavior change is an environment of collaboration, mutual respect, and trust. The manner in which the clinician opens the encounter sets the tone for the entire session. Elements of “Open and Engage” are designed to quickly and effectively create a safe and collaborative relationship to encourage meaningful exploration of health behaviors.
Goals • Establish rapport with your patient • Create a climate of collaboration • Begin your assessment of the patient’s level of self-care activities, educational needs, and emotional response to the health condition • Share pertinent clinical results and education as needed
Tips for Success • Project a warm and friendly attitude with your tone of voice and body language. • Maintain comfortable and culturally appropriate eye contact. • See to the patient’s physical comfort in the exam room. • Comment on something you have learned about the patient in a previous appointment, such as family, job, or hobbies. • Avoid unnecessary medical jargon and use plain language. • Ascertain what the patient wants to talk about. • Ask strategic open-ended question(s). A well-crafted open-ended question can often take the place of a series of closed-ended questions. • Listen attentively, without interruption. • Watch for verbal and nonverbal cues from the patient that add to your understanding of the patient’s thoughts, feelings, and educational needs.
FOLLOW THE ROADMAP 37 Open and Engage
• Introduce yourself and your role • Ask strength-based open-ended question • Offer appreciation Example: What have you done in the • Confirm the reason for the visit past to manage [X]? • State the appointment length • Listen without judgment or interruption • Ask permission to discuss topic • Summarize / reflect change talk • Information exchange as appropriate
Example Clinician: Good morning, Mr. Jones. My name is Jennifer Nelson and I am a Clinical Health Educator. Thank you for coming in to talk with me today. My role is to help patients who are working on healthy behavior changes. Dr. Reynolds asked that we meet to talk about your high blood pressure. [pause] We have about 15 minutes together this morning. Would you be willing to talk about your blood pressure and possible ways to improve your numbers? Patient: Sure. Clinician: Great. Why don’t you begin by telling me about what you’ve been doing to manage your blood pressure? Patient: Well, I’ve been working hard on my diet — lowering the salt and fat. I’ve cut way back on red meat and cheese and salty snacks. It wasn’t easy at first, but I’m getting used to it now. And I even ended up losing some weight — I didn’t really expect that! Clinician: Wow, you’ve been working really hard on eating a healthy diet, and you’ve lost some weight. Congratulations! Healthy eating and weight loss are two important ways to control your blood pressure. I have your blood pressure results from this morning. Would you like to look at them together? Patient: Yes, I’m anxious to see if it’s any better. Clinician: Your reading this morning was 160/98. Your target blood pressure is less than 130/85. What do you think? Patient: Wow that’s great! Last time I was 180/100. Clinician: So you can really see some improvement. Patient: Yeah. ... I guess I’ve still got a ways to go though ... 130/85. Clinician: It’s true that there’s still room to improve. I want to congratulate you again though, on your efforts to date. Clearly your decision to choose healthier foods and the weight loss have helped. The good news is there are a number of other things we can talk about that could help you reach your goal.
38 FOLLOW THE ROADMAP Negotiate the Focus
Overview Most patients, particularly those with chronic conditions, have multiple behaviors to address in order to promote optimal health. People are seldom successful in making several health behavior changes simultaneously. Support your patient to focus on a single topic in each encounter in order to enhance progressive success with health behavior change over time.
Goals • Provide an overview of behaviors that can improve health When deprived • Acknowledge and normalize that change takes time of choice, the only • Emphasize personal choice freedom left is the • Assist your patient to approach self- freedom to say no. management in achievable steps: Encourage him/her to choose a single ALBERT CAMUS area of focus for the encounter • Provide education as needed
Tips for Success • Use option tools, bulleted lists, pictures, or some visual array of choices to present the patient a menu of topics to choose from. See folder for options tools. • Encourage specificity. Use options in a series as needed to narrow the focus of the conversation. • Consider using the options as teaching points for presenting brief key educational messages. • You may wish to start with a blank option tool and fill it in or have the patient fill it in as you speak together. • Write ideas / discussion points on the option tool during the encounter. • Invite the patient to take a copy of the option tool home, if appropriate.
FOLLOW THE ROADMAP 39 Negotiate the Focus
• Offer options: On this chart are a number of things that can affect . • Elicit patient choice: Is there one area you would like to focus on today? Is there something you’d like to add to the chart, or something else you’d rather talk about? • Evoke change talk: What are some reasons to consider making this change now? • Listen / reflect change talk • Information exchange as appropriate
Example Clinician: On this chart are a number of other things we can talk about that could help you reach your blood pressure goal. Would you be interested in taking a look at some of the options? Patient: Yes, I would. I really want to get this blood pressure under control! Clinician: Here are some things that will help improve blood pressure [show option tool]. They include, healthy eating — you have a great start on that one. Monitoring your blood pressure at home can also help you and your physician get a better picture of your blood pressure. Physical activity means working up to 30 to 60 minutes a day of moderate exercise. Medications, weight management, and smoking cessation can also help. Eventually we encourage you to try all of these approaches. Of course, it's up to you to decide which you'd like to do first. I’m wondering which of these areas you’d like to focus on today. Or perhaps you have another idea — we could write that in a blank circle. Patient: Well, I think I’m doing okay on the eating and weight … I don’t smoke. I have been thinking that it wouldn’t hurt to get some exercise. Clinician: So exercise has been on your mind. What are some reasons to consider making this change now? Patient: Getting some exercise might help me feel better, and it seems like it will help my blood pressure too. Clinician: You’d like to feel more energetic. You also have your eye on improving your blood pressure. I hear that you value your health and vitality. Patient: Exactly. Clinician: When you think of exercise, what does that look like to you? Are there certain activities you particularly enjoy? Patient: I don’t know. What types of exercise could really help? Clinician: You can try anything that gets your heart rate up, gets you breathing faster, and sweating a bit. We recommend starting slowly and increasing over time to 30 to 60 minutes of movement a day. It doesn’t have to be all at once. You can do several shorter sessions throughout the day. Some ideas inlcude: jogging, swimming, walking, aerobics ... or you may have ideas of your own. Patient: I’m not exactly in great shape anymore. I guess I could try walking.
40 FOLLOW THE ROADMAP Assess Readiness
Overview Assessing readiness helps the clinician and the patient gauge how ready the patient is to consider adopting a new behavior. The readiness ruler is an efficient tool for measuring how a patient feels about making a change. Exploring readiness helps the patient uncover and build their motivation for change, and guides the clinician to effectively tailor the intervention to the patient’s particular level of readiness.
Goals • Assess the patient’s level of readiness to adopt a new behavior • Elicit change talk • Assist the patient to identify positive aspects of the behavior • Assist the patient to identify barriers to success • Mirror the patient’s thoughts and feelings about the behavior
Tips for Success • Think of motivation as a vital sign and the ruler as a way to measure it. • Demonstrate a neutral stance throughout this process with your language, tone, and body language. • Ask the straight question to understand the patient’s perception of the readiness number chosen. The patient’s 5 might be your 3. • The backward question is a simple way to elicit change talk. This question invites patients to consider the reasons making a change might be important for them. Listen for change talk, and reflect. • The forward question can help to identify barriers to success. It can also help the patient begin to imagine what it would be like to make the change. • When summarizing, begin with the ideas that support the current behavior and end with the ideas that support movement toward change. This can help enhance motivation. • Remember, the ruler starts with zero. When asked to rate their readiness, people will rarely pick a zero. This allows you room for the backward question, “Why a 1 and not a zero?” to elicit change talk.
FOLLOW THE ROADMAP 41 Assess Readiness
• Ruler or Readiness Scale 0–10 • Straight Question: Tell me about a 5? • Backward Question: Why a 5 and not a 2? (move down 1 or 2) • Forward Question: What would need to be different to move from a 5 to a 7 or 8? (move up 1 or 2) • Listen for change talk. Summarize
Example Clinician: So walking is of interest to you. To help us both understand how you feel about beginning a walking program, I have a ruler here that goes from zero to ten. If zero is not at all ready and ten is completely ready, how ready would you say you are right now to begin a regular walking program?
Patient: Hmm … I guess I’m a 5.
Clinician: What does a five mean to you?
Patient: Well, it seems like a good idea, but I’m not sure how I’d find the time. I know you said I’d start out slow, but knowing I’d eventually need to find an hour a day … I don’t know.
Clinician: So it’s hard to know when you’d fit it in. And, you picked a 5 and not a 3. Tell me about that.
Patient: I know I need to get this blood pressure down! I don’t want to worry about a heart attack or stroke. I’d hate to burden my family if I got sick. That’d be awful.
Clinician: For you, health is a priority and managing your blood pressure would help prevent a significant health event. You want to lead an active life and be around for your family.
What would it take to move you up a bit, say to a 7 or 8?
Patient: I don’t know … maybe it would be easier to start next month, after I finish this big project I’m doing at work.
Clinician: On one hand, you’re feeling pretty busy at work right now and fitting in the walking could be a challenge. On the other hand, you would like to get your blood pressure under control and not have to worry about your health. I also heard it would be helpful to start a walking program after you finish your big project at work. Did I get it all?
Patient: Yes, you sure did.
42 FOLLOW THE ROADMAP Tailor the Transition: The Patient Who Is Unsure*
021 345 678910
Overview Tailoring the transition provides a bridge from assessing readiness to the close.
About 80% of the patients we work with will initially feel uncertain about making a change. Our job as clinicians is to assist our patients to fully explore and perhaps resolve their ambivalence. This process creates a clear picture of both sides of making a change. Patients can then use this information over time to help them decide when to change (or not), and when the time is right, pursue a course of action.
Goals • Assist patients to evaluate their ambivalence • Elicit change talk and soften sustain talk • Develop discrepancy • Encourage the patient to consider next steps Tips for Success • Summarize the patient’s perspective, ending with their change talk or reasons to consider change. This allows your patient to hear their own argument for change. • After summarizing, ask for the patient’s evaluation: “Where does that leave you now?” or “What might be a helpful next step as you think about this change?” • Avoid premature action planning. Action planning with a patient who is ambivalent is likely to result in failure to adhere to the plan. • Redefine success. A successful encounter with the patient who is ambivalent may be that the patient agrees to think more about the issue, talk to others about it, or learn more about the subject.
* Strategies for tailoring the transition for patients who are not ready for change can be found on pages 45–47 and those who are ready for change on pages 49–51.
FOLLOW THE ROADMAP 43 Tailor the Transition: The Patient Who Is Unsure
Not Ready (0–3) • What might need to happen for you to consider ? • Raise Awareness • Would you be interested in knowing more about ? • Elicit Change Talk • What kind of follow up or resources would be helpful for you? • Advise & Encourage • Reflect change talk, summarize as appropriate
Unsure (4–6) • What do you see as your next steps? • Resolve • What are you thinking / feeling at this point? Ambivalence • Where does fit into your future? • Elicit Change Talk • Reflect change talk, summarize as appropriate • Build Readiness
Ready (7–10) • What are your ideas for ? / How might you do it? • Strengthen • How might your life be different when you make this change? Commitment • What barriers might you encounter when making this change? • Elicit Change Talk • How might you work around the barriers? • Negotiate Plan • Reflect change talk, summarize as appropriate
Example with Unsure Patient Clinician: Let me take a moment to share what I’ve heard thus far. Right now it would take some time to figure out how to fit walking in your schedule. You are committed to your health and your family. Also, you want to feel more energy and stamina to really live life. Did I get it right? Patient: Absolutely. Clinician: Where does that leave you now? Patient: Well, I’m going to need to think about it some more. Maybe I’ll talk to my wife about it too. I need to see whether I could really fit it in once I’m done with this project at work. It’s always tough to figure out how to do it all — job, kids, all that. I guess taking care of myself usually goes to the end of the list. Clinician: Yes, there are a lot of things to consider. It sounds like you’d like to think this through on your own then decide on a next step. Patient: Right. Well, you got me thinking, that’s for sure. I guess I never really looked at it this way before — I mean the way taking care of myself is important for taking care of my family. Like I said, I’ll talk it over with my wife tonight. She might have some ideas about this, too.
44 FOLLOW THE ROADMAP Tailor the Transition: The Patient Who Is Not Ready
021 345 678910
Overview The patient who is not ready to change can be both the most challenging and the most rewarding patient to work with. Research supports that this method is particularly effective when working with patients in a precontemplative or “not-ready” stage of change. Nonjudgment and acceptance are key to working effectively with the patient who is not ready.
Goals • Raise awareness • Elicit change talk and soften sustain talk • Advise and encourage • Create a rapport that supports further discussion in the future Tips for Success • Nonjudgment is paramount When you feel your judgments rising, step back and reframe. Tap into your curiosity and empathy for the person you are working with. • Listen-Listen-Listen Listen with compassion and empathy. Use open-ended questions and reflective listening strategically to guide your patient to explore the issue and build motivation for positive change. • Soften Sustain Talk Opposing a patients sustain talk tends to reinforce it. When a patient verbalizes reluctance to change (often heard as arguing for the status quo, challenging the clinical data, interrupting, blaming others, or minimizing the importance), it is your signal to pause and offer empathy. Use reflective listening to shift the focus of the conversation, and emphasize personal choice and control. • Acknowledge Choice Patients are entirely free to choose whether they wish to make a change. It is not your job to persuade or coerce the patient to change. Rather, act as a guide, a coach, a facilitator to assist the patient to access his/her own motivation for change. • Redefine Success A successful encounter with the patient who is not ready may be simply to raise awareness of an issue and help the patient begin to think about it. Acknowledge and accept the patient’s current state of readiness. Doing so will create a positive rapport that leaves the door open for follow up.
FOLLOW THE ROADMAP 45 Tailor the Transition: The Patient Who Is Not Ready
Example for Not Ready Patient Clinician: So you picked a 2. Tell me about a 2? Patient: You know, I like my cigarettes! I’ve been smoking for over 30 years and I just don’t want to quit. Clinician: Your cigarettes have been there for you, for many years. Patient: Yes. You got it. Clinician: Yet you picked a 2 and not a 0 or a 1. Patient: Well, yeah. I know smoking’s not good for me, especially since I had the heart attack. I probably should quit some time, but I really don’t want to. Not right now. Clinician: This is not the right time for you. Perhaps in the future but not now. Patient: Yeah, it would take a lot to get me to change. Clinician: Funny you say that. I’m curious what would it take for you to feel more ready to think about quitting? Patient: I don’t know ... maybe if they raise the price again, cigarettes are so expensive! I can’t believe how much they cost. Or maybe if all this other stuff doesn’t work to get my blood pressure down. I’m working hard on the diet and exercise and I’m taking the pills. To tell you the truth, the main reason I’m doing all that is so I don’t have to quit smoking. Clinician: So from your perspective giving up smoking is kind of a last resort. You might consider it if nothing else works. Patient: I guess you could say that, yeah. I really think the other stuff is enough. Clinician: You feel like you’re doing all you can right now. Patient: Exactly. I mean, I enjoy smoking. Some people do it out of habit, but I like the taste, the image. You know when I started in college, smoking was cool, so I liked that. I know it sounds weird, but now that smoking is uncool, I like that, too. I kinda like bucking the system. Clinician: Ah, you like to make your own decisions. Independence is important to you. Patient: Yes. My life is pretty crazy. I’m a single parent. My boys are in their 20s, but they both still live at home. Their friends are always in and out. And I have a job where I travel a lot. I guess in a way the cigarettes are one thing that I can count on. They’re perfect with a cup of coffee, or after a meal, or on a break. I guess they really help me relax.
46 FOLLOW THE ROADMAP Tailor the Transition: The Patient Who Is Not Ready
Clinician: So your cigarettes are really dependable, especially when other things in your life are hectic. There is no downside in your view. Patient: Well, like I said, I don’t like the cost. And I don’t like that my kids smoke. I hate to see them hooked so young, but I can’t really say anything if I’m smoking, can I? And my ex is always blaming me for being a bad influence, he’s one of those health nuts, you know? Always jogging or going to the gym. I hate his nagging. Clinician: What else? Patient: I don’t like thinking I could have another heart attack. It wasn’t a real bad one, but it was pretty scary. And my older boy, his girlfriend is pregnant. She stays with us. I’m kinda looking forward to being a grandma and having a baby in the house — I know I shouldn’t smoke around a baby ... Clinician: So on the one hand, smoking is something that’s been with you for a long time and it’s something you can rely on in your busy life. Also you like the image of smoking. On the other hand, you’re uncomfortable about the example you’ve set for your sons, you have a grandchild on the way and you feel you shouldn’t smoke around the baby, and you don’t want to repeat the scary experience of having a heart attack. Patient: Yeah. Clinician: Thinking about all that, what do you think is next for you? Patient: I don’t know. I probably should quit some time but I really don’t want to right now. It’s just too much to think about right now, what with my job, the kids, and all. I think the diet and exercise and the blood pressure pills will be enough. Clinician: Ms. Morgan, thank you for being willing to talk with me about smoking. I appreciate your honesty. Also, I feel obligated to let you know that stopping smoking is the most important thing you can do right now to improve your health. Continuing to smoke definitely puts you at higher risk for another heart attack. At the same time, I recognize that the decision to quit is truly yours, and I hear that right now, you’re not ready to quit. I know that if there comes a time when you feel committed to quitting, you can find a way to do it. There are a number of programs here at Kaiser Permanente to help you if you like. I would be glad to talk with you more about our programs in the future if that is of interest to you. Patient: Okay, I’ll keep that in mind. Thanks.
FOLLOW THE ROADMAP 47 The more an individual feels truly accepted for his current behavior, no matter how unhealthy, the more likely he is to consider change.
ROGERS, 1959
48 FOLLOW THE ROADMAP Tailor the Transition: The Patient Who Is Ready
021 345 678910
Overview One challenge in working with the ready patient is managing our own enthusiasm as well as the patient’s action planning. As a provider, avoid the temptation to create the plan yourself. Patients are more likely to adhere to the plan if they feel supported in building commitment and have designed their own plan.
Warning! Even the most carefully crafted plan can be sabotaged by unforeseen circumstances. If a patient returns and reports a “failure” to carry out the plan, help to normalize the experience as part of the natural cycle of change, and encourage the patient to use the experience to adjust their plan and continue forward.
Goals • Strengthen commitment Concerning all • Elicit change talk acts of initiative • Advise and encourage and creation, there • Negotiate an achievable plan is one elementary truth — that the moment Tips for Success one definitely commits • Remember, ambivalence may still be oneself, then providence present even when someone is ready to moves too. change. Take time to explore the patient’s level of commitment to change. JOHANN WOLFGANG VON GOETHE • Elicit change talk and strengthen commitment by encouraging the patient to verbalize why the change is important. • Build motivation by encouraging the patient to visualize what it will be like to actually make the change, “What will be the impact on health, well-being, and relationships?” • When planning, elicit the patient’s ideas for the plan. • Help the patient plan for success by encouraging identification of potential barriers to carrying out the plan and ideas for working around the barriers. • Check the patient’s level of confidence to carry out the plan using the confidence ruler. If confidence is low, work together to create a more achievable plan.
FOLLOW THE ROADMAP 49 Tailor the Transition: The Patient Who Is Ready
Example for Ready Patient Clinician: So you picked an 8. Why an 8?
Patient: Because I really want to get this diabetes under control!
Clinician: Why is diabetes control so important to you?
Patient: I don’t want to end up like my mom did ... on dialysis, nearly blind. Her life was miserable for so many years. I don’t want that to happen to me.
Clinician: You want to do everything you can to stay healthy.
Patient: That’s right. I want to take charge of this diabetes, it’s not going to control me!
Clinician: You sound very determined. What are your ideas for monitoring your blood sugar at home?
Patient: Well, I figure I can check it 4 times a day, just like they said in the class. I already got the monitor and I’ve tried it a few times — it’s not too bad. I think I can do it.
Clinician: And how do you think checking regularly will help control your blood sugar?
Patient: It will let me know how I’m doing with my diet and exercise. If my sugar is high, I can take a walk. If it’s low, I can have a snack. If I just can’t seem to get it right, I can call my care manager and talk with her about it — maybe change my medicine or something.
Clinician: So this is a way for you to really fine-tune your control and to know how your diet and exercise are working to balance your blood sugar. It will also provide information for you and your care manager as you consider your ongoing care.
Patient: Right!
Clinician: I’m curious, have you thought of ways to remind yourself to check your blood sugar?
50 FOLLOW THE ROADMAP Tailor the Transition: The Patient Who Is Ready
Patient: I figure I can just check it at mealtime and bedtime. Since I’ve had diabetes, I’m regular with my meals.
Clinician: Ah, so at breakfast, lunch, dinner and at bed. What if anything might get in the way of you following through?
Patient: Hmm ... well, it might be kinda hard to do at work. I mean, bringing the monitor back and forth, finding a private place to do the test ... I don’t know.
Clinician: So, it could be a little tricky while at work.
Patient: Yeah. I don’t know. Maybe it would be easiest to have another monitor — one that I just keep at work, but I can’t really afford that. I guess I could carry the stuff back and forth. And I could probably do the checking in the restroom. I think that would work.
Clinician: OK, it sounds like you’ll check your blood pressure four times a day, at mealtimes and at bedtime. You’ll bring your monitor and supplies back and forth to work, and you’ll check your blood sugars in the restroom at work. Did I get it right?
Patient: Yep.
Clinician: I’d like to ask you another scale question. This one is a little different. On a scale of 0 to 10, how confident are you that you will be able to follow this plan?
Patient: Hmm. Realistically, about a 5.
Clinician: Tell me more about the 5?
Patient: Well, again, I’m just not sure how it will be to check it at work. I hadn’t really thought that one through.
Clinician: I’m wondering whether you’d like to adjust your plan a bit so that you feel more confident in your ability to succeed?
Patient: Well, maybe I should just concentrate on checking 3 times a day. Breakfast, dinner, and bedtime ... and not worry about work just yet. I’m totally sure I can do that, no problem.
Clinician: So you feel very certain you’ll be able to check 3 times a day.
Patient: Yes. I can definitely give that a try. I know I can do it.
FOLLOW THE ROADMAP 51 Close the Encounter
Overview Closing the encounter provides an opportunity to wrap up the session, offer succinct advice, express confidence, and arrange follow-up as necessary. These elements affirm the collaborative nature of the patient-clinician relationship and encourage the patient to take an active role in self-care.
Goals • Bring the session to closure • Offer succinct advice • Express confidence in the patient’s capacity to change • Arrange for follow-up and link with appropriate resources or specialty care
Tips for Success • Keep your advice clear and succinct. Less is more. • Accept and acknowledge the patient’s perspective. Emphasize personal choice. • Create a confidence statement that is genuine and realistic. • Make appropriate referrals: Remember you are one member of the health care team. Consider your patient’s needs and facilitate the comprehensive care they deserve by making referrals as appropriate.
52 FOLLOW THE ROADMAP Close the Encounter
• Show appreciation • Affirm positive behaviors • Respectfully acknowledge decisions • Offer advice if appropriate • Emphasize choice • Express confidence • Arrange follow-up and link with available resources
Example Clinician: Mr. Jones, I want to thank you for coming in today and for being willing to talk about managing your blood pressure. Again, congratulations on your healthy eating and weight management. You’ve really been working hard in those areas and your efforts are paying off.
I want to emphasize that regular physical activity is another powerful way to manage your blood pressure and improve your overall well-being. I encourage you to begin exercising regularly. I also recognize that the decision to do this is entirely up to you. And I’m confident that if you choose to begin an exercise program, you will find a way to fit it into your life that works for you.
Would you be willing to talk again in about 3 weeks to discuss your progress as you think this through?
Patient: Yes, that would be great. Thanks so much for your help today, Jennifer.
Clinician: You’re welcome, Mr. Jones. Please take this slip to the front desk to make your return appointment. I look forward to seeing you again.
Patient: Okay. Bye.
Clinician: Good-bye.
FOLLOW THE ROADMAP 53 54 MOTIVATING CHANGE TOOLS Developing Competency in Motivating Change Achieving proficiency with the motivating change method requires time and practice. This section is designed to assist you in your individual exploration and development with the method. You will find some general guidelines as well as key questions, practice scenarios, and checklists for each step of the roadmap. These worksheets are intended to encourage you to analyze your style, skills, and experience and to build your expertise and effectiveness when working with patients to support health behavior change.
The worksheets are to be used as you see fit. You may choose to go through them systematically over time as you practice your skills. You may wish to refer to them after a particularly interesting, successful, or challenging encounter in order to clarify the lessons from that interaction. You may wish to jot down your answers to the questions, or use the questions simply to trigger your thinking and internal work toward comfort and competence. Use this section in whatever way suits you best to deepen your understanding and application of motivating change method.
56 DEVELOPING COMPETENCY IN MOTIVATING CHANGE Patients as Teachers
As you refine your motivating change skills, your patients may be your best teachers. Each clinical encounter provides an opportunity to develop your skills and style. Pay attention to how your patients respond and learn from their feedback. During your encounters, evaluate the following:
Talk Time If your patients are doing more of the talking than you are, you’re on the right track. If not, consider asking Patience an open-ended question, offering a reflection, or and perseverance listening more attentively. have a magical effect before which difficulties Sustain Talk disappear and Is your patient arguing, challenging, rationalizing, obstacles vanish. blaming, minimizing, or ignoring? If your patient is verbalizing sustain talk, think about what happened JOHN QUINCY ADAMS just before they started reacting. What did you say or do that might have elicited this response? Consider returning to the core skills of ask, listen, and summarize to reduce sustain talk, decrease any potential discord, and enhance motivation.
Change Talk Change talk has been linked with positive behavior change. If your patient is sharing change talk (reasons, hopes, confidence, or intentions for change) your approach is serving to enhance motivation. Continue to ask open-ended questions, reflect, affirm, listen, and summarize.
Self-Talk How do you feel at the end of the encounter? Was it more like a sublty choregraphed dance or more like a wrestling match? If you are feeling satisfied with the interaction and feel that you assisted your patient with exploration and problem-solving, you are likely on the road to proficiency with motivating change. If you are exhausted and feeling as though the encounter was an uphill climb, don’t despair. Perhaps you are trying some new approaches that will become easier with practice. Remind yourself to use strategies that encourage your patient to do more of the talking and more of the work. Remember, adopting a new practice style takes time. Be patient with your own process and learn as you go.
DEVELOPING COMPETENCY IN MOTIVATING CHANGE 57 Open the Encounter
Review the guidelines for Opening the Encounter in the Follow the Roadmap section of this manual, then complete these questions.
1. Write an opening that you might use in your clinical practice.
2. Write several open-ended questions that might be particularly useful in your practice. Think about the information you like to gather in your opening and the things you’d like to learn about your patient, and formulate some open-ended questions that are likely to elicit the information you seek.
3. Focus on several actual openings in your clinical practice. You might choose to concentrate on your first encounter each day for a week, or to all encounters one morning or one afternoon. Think ahead about how you’d like to construct your opening. Incorporate your ideas from practice questions 2 and 3 above. After the encounter, as you reflect on each opening, ask yourself, “Did I ...”: ❍ Introduce myself and my role clearly? ❍ Let the patient know the reason for the visit? ❍ Set the length of the visit? ❍ Ask permission to discuss the topic? ❍ Ask an open-ended question (was it strength-based)? ❍ Listen attentively without judgment or interruption? ❍ Summarize or reflect what I heard the patient say, especially change talk? ❍ Share clinical results or education as needed?
4. What went well with this opening? 6. How did the patient respond? What would I do differently next time?
7. What have I learned about opening the encounter that will help me continue to be successful in establishing rapport 5. Were my open-ended questions with my patients? successful in eliciting the information I wanted?
58 DEVELOPING COMPETENCY IN MOTIVATING CHANGE Negotiate the Focus
Review the guidelines for Negotiate the Focus in the Follow the Roadmap section of this manual, then complete these questions.
1. What has your experience been with 6. What has your experience been with negotiating the agenda? using the option tools in a series?
2. Which option tools seem most appropriate for your practice? 7. How have your patients responded to the option tools?
3. What are your ideas for integrating option tools into your practice?
8. What differences have you noticed in an encounter when you used an option tool, compared with an encounter when you didn’t use it? 4. Have you created your own option tool? If so, what are the options you included? (If you’d like to share your tool with others, see Customizing an Option tool in the folder pocket.)
9. What alternative ideas do you have 5. What do you see as the benefits of for negotiating the agenda (pictures, using the option tools? blank tools, or handouts)?
DEVELOPING COMPETENCY IN MOTIVATING CHANGE 59 Assess Readiness
Review the guidelines for Assess Readiness in the Follow the Roadmap section of this manual, then complete these questions.
1. What has your experience been with 4. How does the readiness number assessing readiness? your patients pick correlate with the number you think they will pick? Any surprises?
5. What benefit do you see in assessing readiness? 2. How have your patients responded to the readiness ruler?
6. What are your ideas for making the ruler a part of your everyday practice?
3. Cite an example of change talk from one of your patients in response to the backward question. 7. What alternative ideas do you have for assessing readiness (continuum with pictures, stoplight red-yellow-green, or other)?
8. How confident are you in your ability to use the ruler effectively? What might boost your confidence?
021 345 678910 NOT CONFIDENT TOTALLY CONFIDENT
60 DEVELOPING COMPETENCY IN MOTIVATING CHANGE Working with the Patient Who Is Unsure
Review the guidelines for working with the unsure patient in the Follow the Roadmap section of this manual, then complete these questions.
1. What open-ended questions have 5. From your experience, what are the signs you found to be most effective when of a successful encounter with an unsure working with the unsure patient? patient?
6. What are the biggest challenges for you when working with the unsure 2. How do you “hold the reins” on action patient? planning with the unsure patient?
7. What are your ideas for overcoming 3. How do you feel when an unsure patient the challenges? leaves your office without a specific action plan?
8. Briefly describe a successful encounter you’ve had with a patient who was 4. What has been your experience ambivalent about change. What made when working with unsure patients the session successful? What are the over time? What are the follow-up implications of these observations on encounters like? your personal practice style?
DEVELOPING COMPETENCY IN MOTIVATING CHANGE 61 Working with the Patient Who Is Not Ready
Review the guidelines for working with the patient who is not ready in the Follow the Roadmap section of the manual, then answer these questions.
1. Which open-ended questions have 5. What do you like about working with you found to be most effective when the patient who is not ready? working with the patient who is not ready?
6. What are the biggest challenges for you when working with the patient 2. What “pushes your buttons”? How is who is not ready? your practice style altered if a patient sets off a strong reaction inside you?
7. What are your ideas for overcoming the challenges? 3. How do you “hold the reins” on judging, lecturing, telling, defending and persuading when confronted with a patient who is not ready?
8. Briefly describe a successful encounter you’ve had with a patient who was not ready to change. What made the session successful? What are the 4. What has been your experience when implications of these observations on working with patients who are not ready your personal practice style? over time? What are the follow-up encounters like?
62 DEVELOPING COMPETENCY IN MOTIVATING CHANGE Close the Encounter
Review the guidelines for Close the Encounter in the Follow the Roadmap section of the manual, then answer these questions.
1. Write a closing that you might use in your clinical practice.
2. Focus on several actual closings in your clinical practice. You might choose to concentrate on your first encounter each day for a week, or to all encounters one morning or one afternoon. Think ahead about how you’d like to construct your closing. Incorporate your ideas from practice question 2. After the encounter, as you reflect on each closing, ask yourself, “Did I …”: ❍ Thank the patient for coming in / being willing to explore the issue? ❍ Affirm positive behaviors? ❍ Respectfully acknowledge decisions? ❍ Offer my professional advice? ❍ Emphasize choice? ❍ Express confidence? ❍ Arrange for follow-up? ❍ Link with appropriate resources?
3. What went well with this closing? 6. How did I express confidence? Was my confidence statement genuine and realistic? How did the patient respond?
4. What would I do differently next time?
7. What have I learned about closing the encounter that will help me continue to be successful in concluding the appointment and maintaining rapport with my patients? 5. How did I give advice? Was my advice clear and succinct?
DEVELOPING COMPETENCY IN MOTIVATING CHANGE 63 Provide Education
Review the guidelines for Providing Education in the Information Exchange section of the manual, then answer these questions.
1. When providing education or reflecting on previous educational encounters with patients, ask yourself, “Did I ...”: ❍ Assess the patient’s baseline understanding? ❍ Customize the education by building on what the patient already knew? ❍ Lecture? ❍ Overload the patient with information? ❍ Ask whether the patient wanted to take written information home, or did I simply hand it out?
2. How did my patient respond to the education (excited, asking questions, thoughtful, worried, bored, overwhelmed)?
3. Which tools and approaches seem to support my patients to enhance their knowledge and skills for self-care?
4. Which tools and approaches seem to prevent my patients from attaining information that is important to their care?
64 DEVELOPING COMPETENCY IN MOTIVATING CHANGE Share Clinical Results
Review the guidelines for Sharing Clinical Results in the Information Exchange section of the manual, then answer these questions.
1. Thinking about a time when you recently shared clinical results with a patient, ask yourself, “Did I ...”: ❍ Ask permission? ❍ Check the patient’s understanding of the test? ❍ Share the results in a neutral manner and compare them to standards or targets? ❍ Ask for the patient’s interpretation before offering my own? Practice Scenarios 1. Write an example of sharing clinical results that are typical in your practice setting, or choose one of the examples 2–9 below. Your patient’s clinical data: The standard for the test: Your motivating change approach to sharing the results:
2. Write an example of how you would share HgA1C results of 9.8% with your patient. (Goal: < 7.0%)
DEVELOPING COMPETENCY IN MOTIVATING CHANGE 65 Share Clinical Results
3. Your 7 year-old patient weighs 68 lbs and is 46" tall. This means he is in the 25th percentile for height and the 95th percentile for weight for his age. Share this information with the patient and his dad.
4. Write an example of how you would share these Test Patient Goal lipid results with your patient. Total Cholesterol 289 < 200 LDL 152 < 100 HDL 36 > 45
5. Write an example of how you would share a blood pressure reading of 156/98 with your patient (Goal: < 120/80).
66 DEVELOPING COMPETENCY IN MOTIVATING CHANGE Share Clinical Results
6. Write an example of how you would share the results of an office peak flow reading of 285 l/m. (This result is 75% of her personal best of 380 l/m.)
7. Your patient’s dietary survey shows approximately 850 mg calcium ingested each day. Her goal is to take in at least 1,200 mg per day.
8. Your patient’s height and weight indicate a BMI of 36. Using the BMI chart, share this information with her.
9. Your patient with CHF has completed a dietary intake survey. The survey shows his diet contains approximately 4,200 mg sodium per day. The recommended sodium intake for him is less than 2,000 mg per day.
10. Write an example of how you would share the results of a food intake survey with your overweight teenage patient. The survey indicates his diet is about 50% fat. (Goal: 30%)
DEVELOPING COMPETENCY IN MOTIVATING CHANGE 67 Advice, Choice, and Confidence
Review the guidelines for Offering Advice and Expressing Confidence in the Information Exchange section of the manual then answer these questions.
1. Thinking about the advice you’ve recently given a patient, ask yourself: ❍ Did the patient ask for the advice? ❍ Did I ask permission to give advice? ❍ Did I feel professionally obligated to give advice? ❍ Was my advice statement strong, concise, and clear? ❍ Did I emphasize choice? ❍ Did I express confidence? Practice Scenarios 2. Write an advice statement about an issue that is typical in your clinical setting or choose one of the examples 4–12 below.
3. Write an advice statement for your patient with poorly controlled diabetes who declines to self-monitor blood sugar levels.
4. Write an advice statement for a parent who declines to vaccinate her baby.
5. Write an advice statement for your patient who is post MI and declines to consider smoking cessation.
68 DEVELOPING COMPETENCY IN MOTIVATING CHANGE Advice, Choice, and Confidence
6. Write an advice statement for your patient with hypertension who declines your recommendation to increase her medication.
7. Write an advice statement for your patient who has severe asthma and declines to use her steroid (preventive) inhaler.
8. Write an advice statement for your patient who is at high risk for breast cancer and declines to conduct regular breast self-exams.
9. Write an advice statement for your patient who is overweight, has made all the dietary changes she feels she can, and declines to exercise because she “doesn’t have the time.”
10. Write an advice statement for your patient who has CHF and declines to engage in regular physical activity.
11. Write an advice statement for your teen patient who declines to use condoms during sex.
12. Write an advice statement for your CCC patient who declines your recommendation to move from her home to an assisted living facility.
DEVELOPING COMPETENCY IN MOTIVATING CHANGE 69 Observer Worksheet
Recognizing Key Elements of the Brief Negotiation Model
KEY ELEMENTS TALLY COMMENTS / EXAMPLES Open-ended questions
Closed-ended questions
Reflection
Affirmation
Summary
Change talk
Resistance
Expression of confidence
70 DEVELOPING COMPETENCY IN MOTIVATING CHANGE Observer Worksheet
Recognizing Key Elements of the Motivating Change Model
KEY ELEMENTS TALLY COMMENTS / EXAMPLES Open-ended questions
Closed-ended questions
Reflection of change talk
Affirmation
Summary
Expression of confidence
Patient change talk
Patient sustain talk
DEVELOPING COMPETENCY IN MOTIVATING CHANGE 71
Motivating Change History, Theory, and References Motivating Change History
1982 interviewing,” is incorporated into research studies of behavior change within primary Motivational Interviewing care settings. Begins in a Barbershop While working out of a former barbershop 1993 during his sabbatical in Bergen, Norway, William R. Miller, Ph.D., conceptualizes his KP-CHR Staff Train Health own version of “good therapy” in working with Professionals in Simplified addictive behaviors. He calls this therapeutic Version of MI approach motivational interviewing (MI), and describes it in a seminal article published in KP-CHR staff gain experience in training Behavioral Psychotherapy. health professionals in medical motivational interviewing by providing extensive training to research interventionists working across 1988 the country in national clinical trials: Trials of Hypertension Prevention (TOHP); Dietary Motivational Interviewing Works! Intervention Study in School Age Children (DISC), and the Women’s Health Initiative (WHI). Initial studies support the efficacy of MI in triggering behavior change for a variety of addictive behaviors. A New Name: Brief Negotiation Stephen Rollnick, coauthor of motivational interviewing, travels to Oregon and spends 1992 a week consulting with CHR behavioral intervention team. Rollnick is asked: “So, A Brief Form of Motivational what in the heck do we call this briefer, Interviewing Comes to Life more structured adaptation of motivational interviewing? His response: “To avoid Steve Rollnick and colleagues (1992) publish confusion with the more lengthy, specialist- a seminal paper describing a brief form of based motivational interviewing method, MI developed in a medical setting for use in I suggest you call your adaptation, ‘brief brief consultations. negotiation’ (BN).” Motivational Interviewing Simplified at Kaiser Permanente 1994 Researchers at the Northwest Region of Brief Negotiation Works! Kaiser Permanente’s (KP) Center for Health Research (CHR) adapt and simplify MI— Initial research studies suggest that BN— and integrate with the above theory and and related brief motivation-focused research—into a strategy-based health interventions—are effective in enhancing behavior change counseling method for use health behavior change in both hospital by general health care professionals in brief and primary care settings. In particular, BN clinical encounters (5 to 20 minutes). This is identified as being effective for nonhelp model, initially called “medical motivational seeking patients, and who tend to be in the earlier stages of change. 74 MOTIVATING CHANGE HISTORY, THEORY, AND REFERENCES Motivating Change History
According to a 1999 report from the U.S. 1998 Department of Health and Human Services, there is a “preponderance of evidence KPNC Brief Negotiation Training supporting the efficacy of motivation- Program Commences focused interventions” for enhancing positive behavior across a range of patient Physician Education and Development populations and health behavior change (PED) and Regional Health Education (RHE) goals, including diabetes, pain management, initiate a comprehensive strategy to train medication adherence, weight management, a range of APC clinicians in BN. Training and HIV-risk prevention. program includes:
• Brief negotiation: A 2-day program for 1995 clinicians that provide health behavior change counseling (e.g., clinical health First Brief Negotiation educators, nurses, dieticians). Training Manual • Thriving III: A 6-hour program designed KP-NW staff at Center for Health Research primarily for physicians and nurse draft original version of Kaiser Permanente’s practitioners. BN Training Manual. • Brief negotiation for teams: A 3-session, 6-hour training delivered to APC team to promote a consistent 1996 and unified health behavior change approach. Brief Negotiation Imported • Chronic disease care managers: A to KP Northern California multisession training program includes Staff in KP Northern California learn of an a section on “integrating the BN innovative behavior change counseling method into care management.” method being tested in research studies • Clinical health educators (CHE): A at CHR. Training team from CHR invited to select group of CHE peer mentors facilitate a 2-day introductory training in receives in-depth training in BN, and brief negotiation. clinical observation and feedback skills.
1997 1999 Adult Primary Care Adopts Training Trainers Brief Negotiation as “Standard First team of BN trainers in KP Northern of Practice” California graduate from “Train the Trainers” program. In the context of redesigning the delivery of primary care to adults in KP Northern California (Adult Primary Care [APC]), the brief negotiation method is selected as the “standard of practice” for health behavior change counseling. A series of BN trainings are offered to APC pioneers in 1997. MOTIVATING CHANGE HISTORY, THEORY, AND REFERENCES 75 Motivating Change History
2000 2005 Brief Negotiation: Fresh Look and a New Name: a “Successful Practice” Motivating Change KP’s Care Management Institute (CMI) Training materials (participant manual and endorses brief negotiation as a “successful support pieces) are updated to reflect the practice” for health behavior change refreshed KP Northern California brand counseling. style. The training name is changed to “motivating change” to clarify training Clinicians Enthusiastic about principles and objectives for clinician Brief Negotiation audience. Posttraining evaluations and a survey of over 1,000 health care professionals exposed to 2016 the BN method in KP Northern California rate the training programs highly and felt Motivating Change (MC) Training more confident in working with patients on and Curricula Updates health behavior change. MC training curricula and materials revised based on the 3rd edition of motivational 2001 interviewing text: Miller W. R., & Rollnick, S. (2013). Motivational interviewing: Helping Brief Negotiation 2.0 Is Born people change. New York, NY: Guilford Press. KP Northern California Staff develop a second step training to strengthen basic skills and introduce advanced skills.
2002 Brief Negotiation Expands Horizons: KP-Southern California and Community KP Northern California BN training staff offers a series of 1-day BN trainings to clinicians throughout KP-SC and reaches out with trainings for non-KP community health organizations.
76 MOTIVATING CHANGE HISTORY, THEORY, AND REFERENCES Theory
Theoretical Principles of Motivating Change (formerly called Brief Negotiation) Self-Efficacy, Values, and Belief: Client-Centered Approach • Patients’ belief in their ability to and Acceptance: perform the necessary steps to achieve • A client-centered approach successful behavior change is key characterized by accurate empathy, to motivation and positive outcome. warmth, and genuineness enhances (Self-Efficacy Theory: Bandura, 1982; the likelihood of positive health Gortner et al., 1988) behavior change. (Rogers, 1967) • Perceived clinician confidence in a • A patient-centered approach patient’s ability to change is a powerful significantly contributes to positive predictor of successful outcomes. health outcomes, increased patient (Bandura, 1994; Leake & King, 1977) satisfaction, and increased clinician • People are more powerfully influenced satisfaction. (Stewart, 1995). by what they hear themselves say, • Nonjudgmental acceptance of a than by what others say to them. (Self- patient’s feelings and point of view Perception Theory: Bem, 1972) often creates a climate of openness • Motivation arising from personal to considering change. Lack of core values is more likely to inspire acceptance, coercion, criticism, or successful and lasting change. blame on the part of the clinician (Rokeach’s Value Theory, 1973) generally inhibit change and can • Patients are more likely to make health result in a patient becoming more behavior change if they believe that firmly entrenched in current behaviors. the effort to make the change is worth (Rogers 1967, Miller & Rollnick 2002) the outcome. Perception of the severity of the consequences of inaction Choice and Readiness to Change weighed against the barriers and costs • Ambivalence is a normal part of of making a change are key elements the change process. Working with in attempting health behavior change. ambivalence is working with the heart (Health Belief Model: Hochbaum of the issue. (Miller & Rollnick, 1991) 1958; Janz & Becker, 1984; Protection Motivation Theory: Rogers,1975) • Change is a multistep process with inherent fluctuations in motivation • Adoption of health-promoting and commitment. Relapse is a normal behaviors contributes to personal part of the change process. Matching growth and self-actualization. Important interventions to the patient’s stage of factors for success include perceived readiness can enhance motivation and importance of health, self-efficacy, improve outcomes. (Stages of Change perceived control of health behaviors, Theory: Prochaska & DiClemente, 1986) perceived benefits and barriers to health promoting activities. (Health Promotion Model: Pender, 1990)
MOTIVATING CHANGE HISTORY, THEORY, AND REFERENCES 77 Theory
• Decision-making can be facilitated by weighing the pros and cons of an issue. (Decisional Balance Theory: Janis & Mann, 1977) • Many people make health behavior change on their own without help from health care professionals. (Natural Recovery: Sobel & Sobel, 1993; Prochaska & DicClemente, 1986) • Patients are more likely to succeed with behavior change when the decision to change is based on intrinsic motivation, rather than external or imposed pressure to change. (Deci, 1975)
Style and Success • When told what to do, most people tend to do the opposite. (Reactance Theory: Behm & Behm, 1981) • Patient motivation and resistance are powerfully influenced by the clinician’s interpersonal style. (Miller & Baca, 1983; Miller et al., 1993) • Brief counseling interventions have the potential to produce similar outcomes to longer, more intensive therapy. (Bien et al., 1993; Hollis et al., 1993; Senft et al., 1995; Project MATCH Research group, 1993) • Action planning is only one way to define a successful encounter. Gaining awareness of an issue, agreeing to think about or learn more about an issue, or making a commitment to speak with significant others about the implications of a potential change are a few of the many ways to move forward on the continuum of change. (Prochaska & DiClemente, 1986; Miller & Rollnick, 1991, 2002; Rollnick, Mason & Butler, 1999)
78 MOTIVATING CHANGE HISTORY, THEORY, AND REFERENCES Stages of Change
Precontemplation Contemplation
Relapse & Preparation Recycle
Habit Maintenance Action
Adapted from Prochaska & DiClemente’s Transtheoretical Model of Behavior Change, 1986.
MOTIVATING CHANGE HISTORY, THEORY, AND REFERENCES 79 References
General Bandura A. (1982) Self-efficacy mechanism in Burke B.L., Vassilev, G., Kantchelov, A., and human agency. American Psychologist, 37, 122-147. Zweben, A. (2002). Motivational Interviewing with Couples. In W. R. Miller & S. Rollnick, Motivational Bandura A. (1994) Self-efficacy: The exercise of interviewing: Preparing people for change (2nd control. New York: Freeman. ed. pp. 217-250). New York: Guilford Press. Bem D (1972) Self-perception theory. In L. Carey, K.B., Carey, M.P., Maisto, S.A., & Purnine, Berkowitz (Ed.), Advances in experimental social D.M. (2002). Enhancing readiness-to-change psychology (Vol. 6, pp. 2-62). New York: Academic substance use in persons with schizophrenia: A Press. feasibility study. Psychiatric Services. Psychiatr Serv 53:602-608, May 2002 Bennett, J.A., Perrin, N.A., & Hanson, G. (2005). Healthy Aging Demonstration Project: Nurse Clark, M., Hampson, S.E. Implementing a Coaching for Behavior Change in Older Adults. psychological intervention to improve lifestyle Research in Nursing & Health, Vol 28,187-197. self-management in patients with Type 2 diabetes. Patient Education & Counseling. Vol 42(3) Mar Berg-Smith, S. M., Stevens, V. J., Brown, K. M., Van 2001, 247-256. Horn, L., Gernhofer, N., Peters, E., Greenberg, R., Snetselaar, L., Ahrens, L., & Smith, K. for the Dietary Cordova JV, Warren LZ, Gee CB. Motivational Intervention Study in Children (DISC Research interviewing as an intervention for at-risk couples. Group) (1999). A brief motivational intervention to J Marital Fam Ther. 2001 Jul;27(3):315-26. improve dietary adherence in adolescents. Health Education Research, 14(3), 399-410. Emmons KM, Rollnick S. Motivational interviewing in health care settings. Opportunities and Bien TH, Miller WR, Tonigan JS (1993) Brief limitations. Am J Prev Med. 2001 Jan;20(1):68-74. interventions for alcohol problems: A review. Addiction; 88:315-336. Geller, Josie; Williams, Kim D; Srikameswaran, Suja. Clinician stance in the treatment of chronic Bodenheimer, T. (2005). Helping patients manage eating disorders. European Eating Disorders their chronic conditions. California Health Care Review. Vol 9(6) Nov-Dec 2001, 365-373. Foundation, June. George, L., Thornton, C., Touyz, S. W., Waller, G., & Breckon, J. D. (2005) Exercise motivation and Beumont, P. J. V. (2004). Motivational enhancement adherence: The use of Motivational Interviewing. and schema-focused cognitive behaviour therapy The Sport and Exercise Scientist, 3, 8-9. in the treatment of chronic eating disorders. Clinical Psychologist, 8(2), 81-85. Brehm SS, Brehm JW (1981) Psychological Reactance: A Theory of Freedom and Control. New Goldberg, J.H. & Kiernan, M. (2005). Innovative York: Academic Press. techniques to address retention in a behavioral weight-loss trial. Health Education Research, 20, Brown, Larry K; Lourie, Kevin J. Motivational 439-447. interviewing and the prevention of HIV among adolescents. [Chapter] Monti, Peter M. (Ed); Colby, Gortner SR, Glilliss CL, Shinn JLA, Sparancino PA, Suzanne M. (Ed). (2001). Adolescents, alcohol, and Rankin S, Leavitt M , Price M & Hudes M. (1988) substance abuse: Reaching teens through brief Imrpoving recovery following cardiac surgery: interventions. (pp. 244-274). New York, NY, US: The A randomized clinical trial. Journal of Advanced Guilford Press. xvi, 350 pp. Nursing, 13, 649-661. Burke, B. L., Arkowitz, H., & Dunn, C. (2002). The Hancock, K., Davidson, P. M., Daly, D., Webber, efficacy of motivational interviewing. In W. R. Miller D., & Chang, E. (2005). An exploration of the & S. Rollnick, Motivational interviewing: Preparing usefulness of motivational interviewing in people for change (2nd ed. pp. 217-250). New facilitating secondary prevention gains in cardiac York: Guilford Press. rehabilitation. Journal of Cardiopulmonary Rehabilitation, 25: 200-206.
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Handmaker NS, Wilbourne P. (2001) Motivational Miller WR (1983) Motivational Interviewing with interventions in prenatal clinics. Alcohol Res Problem Drinkers. Behavioral Psychotherapy; Health. 25(3):219-21-9. 11:147-172. The original paper which describes the methods. Harding R, Dockrell MJ, Dockrell J, Corrigan N. Motivational interviewing for HIV risk reduction Miller WR (1987) Motivation and treatment goals. among gay men in commercial and public sex Drugs & Society; 1:133-151. settings. AIDS Care. 2001 Aug;13(4):493-501. Miller WR (1993) What I would most like to know: Hochblaum GM. (1958) Public participation in What really drives change? Addiction; 88:1479- medical screening programs: A sociopsychological 1480. study (Public Health Service Publication No. 572). Washington, DC: US Government Printing Office. Miller WR (1995) Increasing motivation for change. In RK Hester and WR Miller (eds) Handbook of Janz NK & Becker MH. (1984) The health belief Alcoholism Treatment Approaches: Effective model: A decade later. Health Education Quarterly, Alternatives (2nd ed). 11(1), 1-47. Miller WR (1996) Motivational interviewing: Jarvis TJ, Tebbutt J, & Mattick RP (1995) Research, practice, and puzzles. Addictive Motivational interviewing. Chapter 3 in Treatment Behaviors; 21:835-842. approaches for alcohol and drug dependence: An introductory guide (pp.35-50). New York: John Miller WR (1998) Enhancing motivation for Wiley & Sons. change. In W.R. Miller & N. Heather (Eds.), Treating addictive behaviors: Process of change (2nd ed., Jones, K. D., Burckhardt, C. S., & Bennett, J. A. pp. 121-132); New York: Plenum Press. (2004). Motivational interviewing may encourage exercise in persons with fibromyalgia by Miller WR (1998) Why do people change addictive enhancing self efficacy. Arthritis Rheum., 51, behavior? The 1996 H. David Archibald Lecture. 864-867. Addiction; 93:163-172. Johnston BD, Rivara FP, Droesch RM, Dunn C, Miller WR & Baca LM. (1983) Two-year follow-up Copass MK (2002). A randomized controlled of bibliography and therapist-directed controlled trial of motivational interviewing to reduce injury drinking training for problem drinkers. Behavior risk behavior and re-injury rate in adolescents. Therapy, 14, 441-448. Pediatrics, in press. Miller WR, Benefield RG, Tonigan JS (1993) Keller VF & White MK (1997) Choices and changes: Enhanced motivation for change in problem A new model for influencing patient health drinking: A controlled comparison of two behavior. Journal of Communications on Medicine; therapist styles. Journal of Consulting and Clinical 4(6):33-36. Psychology; 61(3):455-461. Konkle-Parker DJ. (2001). A motivational Miller WR, Brown JM (1991) Self-regulation as a intervention to improve adherence to treatment conceptual basis for the prevention and treatment of chronic disease. J Am Acad Nurse Pract 2001 of addictive behaviours. In N Heather, WR Miller, Feb;13(2):61-8 J Greeley (eds) Self-Control and the Addictive Behaviours. Sydney: Pergamon Press. Kushner PR, Levinson W, & Miller WR (1998) Motivational interviewing: When, when and why. Miller WR, C’de Baca J (1994) Quantum change: Patient Care; 32(14):55-72. toward a psychology of transformation. In T Heatherton and J. Weinberger (eds) Can Mallin, R. (2002) Smoking cessation: integration of Personality Change? Washington DC: American behavioral and drug therapies. Am Fam Physician Psychological Association. 2002 Mar 15;65(6):1107-14 Miller WR, Rollnick, S (1991) Motivational M. McMurran (Ed.) (2002), Motivating offenders Interviewing: Preparing People to Change to change: A guide to enhancing engagement in Addictive Behavior. New York: Guilford Press. therapy. Chichester, UK: John Wiley & Sons Ltd. A basic text.
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MOTIVATING CHANGE HISTORY, THEORY, AND REFERENCES 85 Acknowledgments This manual has been developed for use in the Motivating Change 1 and Motivating Change 2 workshops (formerly known as Brief Negotiation). It is intended to support and supplement class discussion and exercises and to provide a resource for on-going skill development for clinicians who complete the workshops.
Mindy Boccio, MPH Primary Author and Motivating Change Program Lead
The content of this manual is gratefully based upon the dedicated work of the following professionals:
Dr. William R. Miller & Dr. Stephen Rollnick For development, dissemination, and research of Motivational Interviewing and active participation in initiating its adaptation as Motivating Change (formerly known as Brief Negotiation).
Denise Ernst, MA and Steven Berg-Smith, MS For development and implementation of initial Brief Negotiation training in the Kaiser Permanente Northwest, for creation of the first Kaiser Permanente Brief Negotiation training manual, and for the introduction of Brief Negotiation to the Kaiser Permanente Northern California Region.
Robyn Hoban, MA, Eileen McAdam, MS, Cecilia Runkle, PhD, MPH For initiation and implementation of the Brief Negotiation program in Kaiser Permanente Northern California (KPNC) and for development of the first KPNC Brief Negotiation participant and trainer manuals.
Sandra Roberts, RN For leading the Brief Negotiating programs wide implementation success and spread to Southern California.
Stacey Deane, MPH and Susan Lebe, MS, RD For editorial review of this manuscript.
Steven Berg-Smith, MS For creating the History timeline included in this manual.
Multimedia Communications For graphic design and production of the manual.
KPNC Motivating Change Training Staff, past and present For their contributions to enhance and evolve the Motivating Change program. We greatly appreciate their on-going commitment to consistently excellent curriculum development and training delivery.
Some photos may include models and not actual patients. © 2017, The Permanente Medical Group, Inc. All rights reserved. Regional Health Education 011786-024 (Revised 8/16) RL 6.8