promoting behavior change in 20 min. or less promoting behavior change in 20 min. or less benton...
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Promoting Behavior Change in 20 Min. or Less
Benton Franklin County Medical Society
February 20, 2015
Daniel O’Connell, Ph.D.
1816 1st Ave W, Seattle, WA 98119
206 282-1007
Dan O'Connell, PhD 2015
Learning Objectives1) Recognize and apply the fundamental
demeanors and behaviors of motivational interviewing
2) Assess and utilize stage of change in guiding your next move
3) Apply these strategies to typical exam room conversations about behavior change
Dan O'Connell, PhD 2015
TOOLS for CliniciansMotivational Interviewing
increase client/family self-motivation for change
Stages of Change to guide interventions by understanding
readiness to consider or take specific actions
Social Learning Theory People are most likely to attempt to do what
they are convinced is useful and what they have confidence they can carry out.
Dan O'Connell, PhD 2015
People are most willing to try change when…
They are reasonably convinced it is necessary and could be helpful
They are reasonably confident they could succeed
It is important enough to them
Commitment is the interaction of all 3 elements.
Dan O'Connell, PhD 2015
From Motivational Interviewing:
Get behavior on the agenda
Acknowledge autonomy
Provide-elicit-provide
Express empathy and normalize
Explore ambivalence
Avoid arguments Roll with resistance
Set limits on yourself rather than the clientDan O'Connell, PhD 2015
Getting behavior on the agenda
Creating an agenda that includes behavioral issues
Establishes dialogue rather than lecture
Activates client and family from the outset
Reluctance to include behavior in agenda is grist for the mill.
Dan O'Connell, PhD 2015
Agenda Setting“What behaviors are you focusing on at home to
help with this?”
“Would it be alright if we talk a bit about…”
“You seem reluctant to talk about___. Can you tell me what is going through your mind?”
“There are a number of things that you can do at home to reduce your risk of another heart attack such as diet, exercise, and quitting smoking. Which would be most helpful for us to talk more about today?”
Dan O'Connell, PhD 2015
Acknowledge AutonomyBoth parties maintain their autonomy
The patient owns the problem
Improvement comes through adherence to a mutually agreed upon plan
Active decision makers have better outcomes
Express concern not criticism or control
Dan O'Connell, PhD 2015
Acknowledge Autonomy
“Obviously this is for you to decide. I am just concerned that you will not have the outcome you want __________, unless you are able to________”
“How important is this to you?”
“”You have to decide if it is worth it.”
“It is hard to decide when you are getting different advice from varying sources.”
Dan O'Connell, PhD 2015
Provide-Elicit-Provide-Elicit
You want dialogue not monologue
Keeps client and family active
Keeps doctor on material that is relevant/of interest to the patient/family
Quickly identifies areas of disagreement and agreement for more efficiency
Dan O'Connell, PhD 2015
Provide-Elicit-Provide-Elicit“I am concerned that the diabetes will cause you
a lot of harm unless you can stick to the regimen more closely. How worried are you about that?”
“The research tells us that losing 10% of the extra weight can be helpful. What are your thoughts?”
“You are reporting all the cardinal symptoms of major depression, which would help to explain why it has been so hard for you to take better care of your health. How does that match up with what you had been thinking?”
Dan O'Connell, PhD 2015
Express Empathy and Normalize
Empathy is communicating that you can see and feel it from the patient’s perspective
Empathy is the lubricant in the conversation and in the relationship Deepens the connection as well as reducing the
friction
Normalizing is respectful and avoids universal hypersensitivity to criticism
Dan O'Connell, PhD 2015
Express Empathy/Normalize (do not agree on hopelessness)
“I know many of my patients feel put on the spot when asked about their ____________.”
“It has been tough hasn’t it.”
“Its natural to be frustrated when you have succeeded and then relapsed in the past.”
“It’s hard to imagine where you would fit more exercise into your day.” (vs. agreeing that it is impossible to fit more exercise in)
Dan O'Connell, PhD 2015
Explore AmbivalenceAmbivalence is completely normal!
Exploring ambivalence openly reduces the “Yes, but…” phenomenon Changes the structure of the conversation from
“Either/or” to “Both/and”
Dan O'Connell, PhD 2015
Explore Ambivalence“I imagine you have a number of different
thoughts and feelings about this.”
“On the one hand ____________, and on the other hand ___________”
“Part of you would like to lose weight, but another part you has lost confidence that it is possible. Tell me more about that.”
Dan O'Connell, PhD 2015
Avoid Arguing/Roll with Resistance
Arguing is a mode of discourse in which no one is listening
It corrodes the relationship poor adherence, no-shows etc.
Learn to hear the argumentative tone in your’s and the client’s voice and be ready to roll with resistance
Dan O'Connell, PhD 2015
Avoid Arguing/Roll with Resistance
“I suppose I do have a different view from you about some of this.”
“Perhaps I am making it sound too easy.”
“You’re right, there are many ways and timetables on which to proceed.”
“Tell me about steps that sound doable from your perspective.”
“I wish we did have a treatment that was less burdensome, and yet this is our most effective approach at the moment.”
Dan O'Connell, PhD 2015
Compassionate Limit Setting(on yourself first)
Frame limits in terms of restrictions on your own behavior rather than theirs. Creates less conflict and accusation Affirms your right to autonomy as a doctor
Anchor your opinion within your profession Providing a more objective, less personal standard
than “I am uncomfortable____.”
Dan O'Connell, PhD 2015
Compassionate Limit Setting “In light of what we know already, this
doesn’t feel like a safe enough plan to me.”
I will have to stop for now as I know there are people waiting to see me. Could we agree to pick this up again _____________?”
“I think we have reached an impasse on this. Would you like to get an opinion from another clinician to compare approaches?”
“There are 3 criteria we use to decide on that. Would it help if we went over them together and see where we stand?”
Dan O'Connell, PhD 2015
Stages of ChangePre-contemplation
Contemplation
Preparation/Commitment
Action
Maintenance Maybe even complete resolution
Relapse J. O. Prochaska and Carlo DiClemente
Dan O'Connell, PhD 2015
Strategies for Pre-contemplator
Ask them to think about this (contemplate) with you Request permission to discuss
Ask questions before giving lectures “What do you think about….”
Focus on data as well as conclusions “There is some evidence that suggests…”
Contrast goals with behaviorDefine your boundaries as part of your
“practice” Acknowledge when an impasse is reached
Dan O'Connell, PhD 2015
Strategies for ContemplatorsElicit perspective: empathy & curiosity
Conviction and confidence
Soften all or nothing thinking “One day at a time”, improvement rather than cure
Explore alternatives
Identify pros and cons of problem and of potential solutions
Elicit self-motivational statements “And why would that be important for you?”
Suggest experiments
Dan O'Connell, PhD 2015
Strategies for Preparation/Commitment
Clarify program, timetable and others’ involvement Referrals, prescriptions, boundaries
Support appropriate self-efficacy While empathizing with doubts
Support family’s right to fully functioning member
Plan for f/u, including “any outcome”
Dan O'Connell, PhD 2015
Strategies to support ActionInterest equals encouragement
Adjust plan for greater success Help identify /overcome obstacles
Anticipate and address early slips
Coordinate with others involved Adherence is precarious without coordination
Schedule follow-up contacts to match support to need
Dan O'Connell, PhD 2015
Strategies for MaintainerYour interest still equals re-enforcement
No news is not good news
Differentiate slip from relapse Early recognition and recovery is easiest
Explore expectations: met/unmet?
Be vigilant for need to intensify action But have a maintenance support schedule in place
even if things are going well.
Dan O'Connell, PhD 2015
Strategies for RelapseExplore last change attempt
Don’t settle for facile, “It didn’t work…”
Identify success as well as setback If they got to relapse it means they were able to
take some action successfully. How did they do it?”
Frame as learning opportunity Suggest another attempt is inevitable
“You have already concluded once that this was important.”
Elicit original reasons for change “Remind me why you felt that quitting drinking
was important when you tried to stop the last time?”
Dan O'Connell, PhD 2015
Putting It All TogetherWe influence clients to see themselves in
a process leading to change.
The client’s success takes time during which motivations converge, knowledge, attitudes and skills are developed and “experiments” are tried and persisted at until improvement is obtained and a new self perception emerges that supports long term maintenance of the most constructive outlook and behavior.
Dan O'Connell, PhD 2015
Reading IdeasO’Connell, D. (2014). Behavior Change. In Behavioral
Medicine: A guide for clinical practice 4th Edition. MD Feldman and Christensen JF eds. Lange: McGraw Hill, Pages 185-194.
Prochaska JO et al Changing for Good . Guilford. 1994 Rollnick S et al. Motivational interviewing in
healthcare: helping patients change behavior. 2007 Guilford Press.
W. R. Miller & S. Rollnick, Motivational interviewing: Helping people change (3rd. edition New York: Guilford Press. 2013
Baumeister RF and Tierney J. 2011. Willpower. Penguin Press, New York
Google for “Motivational Interviewing”
Dan O'Connell, PhD 2015