practical hints and tips for assessing readiness to change - dr bronwen bonfield
TRANSCRIPT
Practical Hints and Tips for Assessing
Readiness to Change
Dr Bronwen BonfieldPrincipal Clinical PsychologistCommunity Neurological Rehabilitation ServiceBuckinghamshire Healthcare TrustNovember 2016
Aims of the SessionTo have increased awareness of
the factors that affect an individuals readiness to change.
To explore the theoretical models that underpin change behaviour
To develop awareness of skills and strategies to support individuals and their families.
CNRS In-Service Background to experience in this area: Multidisciplinary team inservice topic over
the last year. Explored the main question regarding
‘Why don’t some people progress as we would expect (achieve functional change and learn to self-manage their condition), when they present with sufficient levels of physical and cognitive skills to do so?’
Led the team to develop three clinical questions What affects a persons motivation and readiness to change? What skills as clinicians do we need to identify and draw out a
client’s readiness to change within neurological rehabilitation? How can we provide the right therapy, to the right patients at
the right time?
Rehabilitation in MSMuch of neurological rehabilitation is interested
in helping people to manage functional change over the duration of their condition (Therapists in MS delivering the long term solutions 2006).
A growing body of evidence emphasises the importance of effective self management of long-term conditions. It is recognised that those people who successfully self-manage their condition experience better health outcome (Hibbard J & Gilburt 2014)
Self-Management - The importance of well-being
Living a meaningful life that is striving towards what we value promotes well-being.
Each individual will have their own set of values which creates meaning.
When our lives are “in balance” we have capacity to deal with life’s events – whether positive or challenging.
We can enjoy the positives and manage the challenges.
Our lives are like jigsaws – when they fit together to make a whole – again life seems manageable.
However, when we experience stressful life events, changes to our health – our life jigsaw is thrown up in the air, breaks up and lands disjointed.
It takes time, support and advice to get the jigsaw back together and sometimes it does not fit quite as it did before.
Adjusting to this and accepting this new position, physically, emotionally, will enable us to regain balance in our lives.
The Biopsychosocial Model
Biological/Physical Impact
Social ImpactPsychological
Impact
We need to understand the factors that interact and inform our well-being
Challenges in Rehabilitation
‘Why don’t some people progress as we would expect (achieve functional change and learn to self-manage their
condition), when they present with sufficient levels of physical and cognitive skills to do so?’
How our clients presentWhen I get better…….
When I get back to normal
Work within the session –
no carry over
Family report
frustration – no action
Yes….but
Family want more
rehabilitation
The Therapist ResponseThey have potential – I must fix this
Why aren’t they moving forward?
What can I do next?
Frustration
Heartsink
Doubt
Uncertainty
Burn out
Effects of the cycle
Patients remain in therapy for longer periods of time Expressed higher levels of dissatisfaction when
discharged Re-referred quickly either by external referral or self-
referral Therapist dissatisfaction Challenges within the therapeutic relationship
How do we understand this behaviour?
There are multiple models that can inform us: social cognition model, health belief model and stages of change model
We will focus on stages of change model
Precontemplation
Contemplation
ActionMaintenance
RelapseIndividual
leaves Treatment
Stages of Change Model
Precontemplation
Client not intending to change or not aware of the need to do so…
We identify these clients as RED Flag
Contemplation
The individual has some awareness that they have a problem and they are thinking about changing.
We identify these clients as YELLOW flag
Action Actively taking part in behavioural change (e.g. active participant in rehab programme)
We identify these clients as GREEN Flag
In our service we have identified that 60% were green and 40% amber/red
Maintenance & RelapseMaintenance
Making good progress (e.g. taking responsibility for self-management of condition)- this would represent clients who have achieved goals – we may review and then discharge
RelapseClient reverts back to earlier stage of cycle of change
Factors that are barriers to change Lack of awareness of rehabilitation process. Lack of self awareness. Poor insight. Cognitive/emotional deficits. Denial Negative perception of self. Unhelpful belief system/rules for living. Lack of MDT approach. Poor acceptance. Inability to reform values. Inability to remodel self. Feeling powerless. Over protection by others.
Hints & Tips Within any therapeutic relationships key skills are:- Remembering it is a partnership; working in
collaboration- Empathy and compassion - Acknowledging the individuals strengths and
efforts- Open questions- Reflective listening - These are core skills in Motivational
Interviewing - strengthening an individual’s motivation and commitment to change.
Hints and Tips cont… Precontemplation from a service perspective these are clients who need preparation before entering a rehabilitation programme.
- Psychological Group programmes re: acceptance to their condition
Other strategies if this is not available:- Listen and summarise the clients issues- Raise awareness of the benefits of the service available to them- Raise awareness of the disadvantages of staying as they are- Preserve the therapeutic relationship to enable access to the
service at a later date.- Information – leaflet with contact details on. Check the meaning
of the information to the client.
Hints and tips cont…Contemplation Support the client’s problem-solving and
decision making by: - discussing advantages and disadvantages of changing in relation to client (rather than in general)
help client identify where they would like to focus attention first
acknowledge that behaviour change is not easy – provide opportunities for person to voice their reservations about taking action
offer further support e.g. via follow-up appointment
Hints and Tips cont….Agenda Setting
◦Can be a very useful way of identifying current priorities
Hints and Tips cont… Confidence Scales
Using a confidence scale can indicate how the client actually feels about completing a task
For the task to be realistic the rating should be around 6 – 7
0 1 2 3 4 5 6 7 8 9 10
If the client rates the task 8 – 9 – it could reflect something they are already achieving or something that will not move them forward.
If the client rates the task 5 and below it enables further exploration
Hints and tips cont…Action Helping client identify strategies that
work for him/her Acknowledge success to bolster
confidence and self-esteemProvide strategies to help reduce stress
(e.g. relaxation techniques) Set further achievable goals; consider
client keeping diary to monitor behaviour so clinician can help identify what may be preventing progress
Hints and tips cont….Relapse Reinforce to client that this is a
normal experience and does not signify failure Discuss triggers; identify
strategies that have worked so far Help identify where client needs
to jump back onto the ‘wheel’
Hints and tips cont….MaintenanceReinforcing the strategies that
have helped the clientStart bringing in other sources of
community support Agreeing follow-up appointment
or phone call; assurance that support is available if the client needs it
Factors that promote behavioural change Goals Action Phase Use of Motivational Interviewing. Feeling empowered. Peer support. +ve patient/therapist relationship Management of expectations. +ve feedback on performance. +ve outcome facilitating on-going change. Follow-up. Acceptance and re-formulation of values. Ability to remodel self.
Team Considerations Current knowledge
Skills and effectiveness in change behaviours
Evaluate current practices
Identify training needs
Referring OnIf the barrier to change is linked with depression or anxiety then referring to a psychological service will be helpful.
Thank you for listening
Any Questions?
Social Cognition Model
“The beliefs that individuals hold about the outcomes of their actions are key determinants of their health-impairing or health-protective behaviours”
Cognitive representations of health threatEmotional response to health threat
Health Belief Model “The Health Belief Model
assumes that for a person to engage in a recommended health-protective behaviour, they must perceive the benefits to outweigh the costs”