Motivating Change Participant Manual
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Motivating Participant Manual Change NOT FOR DISTRIBUTION Participant Manual, 4th edition Visit online learning programs at kphealtheducation.org. The contents of this workbook may not be reproduced in whole or in part in any form or by any means without written permission from Regional Health Education, The Permanente Medical Group, Inc. © 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