Interventions for Behavior Change

How does behavior change? Need to be clear about underlying model of behavior and behavior change before considering interventions Are there any really well tested and proven models that robustly support use of particular interventions across multiple change tasks (smoking, tobacco use, exercise, etc)? NO But if you find one, please tell the rest of us. So we will do the best we can…

TTM – Stages of Change Model Transtheoretical Model of Behavior Change will be our default choice. Originated with James O. Prochaska in 1970’s Popular book: Changing for Good (1994) Posits individuals move through six fairly distinct ‘stages of change’ in the process of establishing new behaviors While progress is usually sequential, it is not always so Lots of relapsing occurs

Six Stages of Change Pre-contemplation people are not intending to take action in the foreseeable future, and are most likely unaware that their behavior is problematic Contemplation people are beginning to recognize that their behavior is problematic, and start to look at the pros and cons of their continued actions Preparation (Determination) people are intending to take action in the immediate future, and may begin taking small steps towards change Action people have made specific overt modifications in their life style, and positive change has occurred Maintenance people are working to prevent relapse, a stage which can last indefinitely Termination individuals have zero temptation and 100% self-efficacy... they are sure they will not return to their old unhealthy habit as a way of coping

Progressing thru the stages People need awareness of pro’s and con’s – have to make a decision and balance both sides People need a sense they can accomplish the change – self-efficacy Interventions are often aimed at these two elements: awareness and self-efficacy Have to offer interventions consistent with the persons current stage

Strategies by stage Pre-contemplation Raise doubts, increase perception of risks Contemplation Evoke reasons to change, list risks of not changing Preparation (determination) Help pt determine steps to take Action Help pt take steps towards change Maintenance Help pt identify strategies to prevent relapse (↑self-efficacy) Relapse Help pt avoid demoralization and discouragement

Behavior change Regardless of the pt’s stage in the change cycle, the provider must offer SOME intervention at every contact “Five A’s” or “Four A’s” are typical intervention Ask – “Have you smoked any cigarettes in the past month?” Advise – “I strongly advise you to quit smoking” Assess – listen for stage of change, what is needed Assist – offer what is needed – support groups, pharmacological support, etc Arrange – schedule follow up to reinforce decision

A variation – a useful tool Motivational Interviewing is a useful variation for behavioral counseling based on TTM Based on work by William Miller (1983 and after) ‘directive, client-centered counseling style for eliciting behavioral change by helping clients to explore and resolve ambivalence’ Originally use in substance abuse counseling Suitable for 15 minute interventions Evidence is mixed but largely positive

Meet the pt where they’re at… Clients experience ambivalence when faced with recommendations to change Persuasion and logic are very often useless or counterproductive

Ambivalence Motivational Interviewing (MI) assumes ambivalence is a normal part of the change process Rather than ‘fixing’ the client (“righting reflex”), the provider uses evocative words to help the client realize he already has what he needs to solve the problem. Respectful, reinforces autonomy, collaborative

Ingredients of Change: DARN+C&TS Desire for change: “I want to lose weight.” Ability for change: “I know I can do it with the right plan.” Reasons for change: “If I lose weight, I’ll have a n easier time with controlling my diabetes and BP.” Need for change: “I need to lose weight and just stop complaining about having to do it.” + Commitment to change. The amount and timing of change talk is predictive of actual change: “I will start when I get home by tossing out the ice cream that’s left.” & Taking Steps: Action is a key indicator that change will occur: “I ate less last night.”

Two Phases of MI Phase one – Building motivation for change Enhancing confidence Exploring ambivalence Supporting change talk (DARN) Phase Two – Strengthening commitment to change Moving to action Making a plan (C&TS)

MI Spirit Collaboration – how can we work on this together? Evocation – what does the pt think? ELICITING not telling Autonomy – only the pt can decide How to accomplish this? Remain in the spirit of curiosity not authority

Four principles of MI Express empathy (not sympathy) Develop a discrepancy Discrepancy is the difference between how it is now and how the client desires it to be Provider must allow the client to identify the discrepancy Roll with resistance Do not directly oppose client resistance. Provider invites new perspectives. The CLIENT presents argument for change. Support self-efficacy Provider expresses belief in possibility of change and supports the client’s belief the change is possible

Five Skills needed for MI Reflective listening – the heart of MI Selectively offer the statements the pt makes in favor of change (to elicit more such statements)

Reflective Listening Simple reflection – simply state back to the client what was said; substitute new words or make a guess about what the client seems to be saying Complex reflection – add meaning, noting feeling, tone, body language, nuance. Summary – pulls together 2 or 3 client statements into a summary It’s not just what you say but how you say it…need to maintain empathic tone, body language.

Five Skills Needed for MI Asking open ended questions As a rule, providers offer two reflective statements for each open question asked directly Elicit self-motivating statements and change talk

Five Skills… Affirming Can be simple compliments, acknowledging small successes Summarizing Link and reinforce material. Offer pts own reasons for wanting to change back to them. End summary statements with an open question: “What else?” Build pts intrinsic motivation for change

Reflective Listening Seeks to summarize what the client means A reflection makes a guess as to meaning A reflection is a statement, not a question A reflection helps to move the client forward in discussing the concern A reflection establishes empathy

Methods to Elicit Change Talk Ask evocative (open ended) questions Use the ‘importance ruler’ Can ask “on a scale from 1 to 5, where 1 is not at all and 5 is absolutely, how convinced are you that you need to change xyz?” reflect back the pros/cons of change and nudge the decisional balance Ask looking forward questions: what would it be like if you were able to…(stop smoking, etc)? Reflect backwards: how was it before?

Methods to Elicit Change Talk Query extremes What would be the worst possible outcome (if you never stop smoking)? What would be the best outcome if you were able to (stop smoking)? Explore goals and values How does (keeping smoking/quitting smoking) fit with your view of yourself?

Rolling with Resistance Resistance always signals a need for a change in tactics! These are ways to interact that allow exploration and change talk to continue Simple reflection Amplified reflection Double sided reflection Shifting focus Reframing Agreeing with a twist Emphasizing personal choice and control Coming alongside

Strengthening Confidence Talk Ask open ended questions focused on ability Ask a 1-5 scale staging question on confidence Probe for personal strengths and supports Emphasize past success at change Explore hypothetical change and anticipate challenges

Moving to a Change Plan Start with a summary reflection Ask open ended questions about change Provide information and suggestions WITH permission Negotiate a change plan Get a commitment

Providing Information Use “Ask – Ask/Provide – Ask” format Ask what the client already knows Ask if you can offer additional information Provide the information only after you have permission Ask for client thoughts and reactions to the info Then respond with reflective statements, open questions, affirmations, an summarization

Common Traps Confrontation-denial Pt denies need for change or says they can’t do it. Provider argues/persuades Pt digs in; openness to change evaporates Use only Open ended questions Reflections Affirmations Summary

Common Traps Question/answer If provider drills client with questions, get passivity. Try to ask no more than TWO consecutive questions before offering a reflective statement

Common Traps Being “The Expert” The provider has all the answers & the pt doesn’t own the problem Try to get client to offer solutions thru four basic tools Open ended questions Reflections Affirmations Summary

One more trap Premature focus – not finding out what the client really cares about or came to office about. Easy for this to occur when going through a lot of screening questions.

Practice in MI Watch the video taped MI sessions – see links on D2L Find one or (preferably) two willing adult partners to do the assigned exercises Can be fellow students, family or friends Do the “pre-work” exercises that provide observation of more typical interviewing/behavior change techniques. Total project may require more than one session and more than one willing volunteer. Assignment: taped 12-15 minute interview with an adult, using MI techniques (details on D2L under Assignments) accompanied by written self-critique.