Outline Motivational interviewing for behaviour change

Dr Ruth McNair Behaviour change situations in general practice Stages of change assessment Influencing behaviour change
Brief interventions Motivational interviewing

MI
Key concepts How to conduct MI GRACE model practise skills

Semester 12 General Practice 2010

Situations requiring behaviour change

Smoking Nutrition Alcohol Exercise

Stages of Change Prochaska and DiClemente (1982)

Pre-contemplation

Termination

Illicit drug use Screening: e.g. attending for pap smears Risk taking: e.g. sexual health

Contemplation

Maintenance

Preparation

Action

Therapeutic tasks at each stage

Pre-contemplation raise awareness of the potential risks of current behaviour harm-minimisation information to reduce risks

Therapeutic tasks at each stage

Preparation explore and reinforce reasons to change provide practical advice on how to change Action positive feedback

Contemplation tip the balance toward making decision to change

advice - how to respond to relapse situations Maintenance reinforce benefits of change

Influencing behaviour change using brief intervention Definition - information giving and advice about a health-related behaviour - tailored to individual patient needs - patient initiated or opportunistic (doctor initiated) Time - often takes less than 5 minutes Evidence that brief advice by a doctor can influence change regardless of the stage of change

Brief intervention example - 5As Approach

Developed for smoking cessation Ask screen for unhealthy behaviours Assess readiness to change Advise behaviour to alter Assist practical help to effect change Arrange follow up to support

From SNAP guide RACGP, 2004

Brief intervention example Decision Balance Sheet

Patient home-work to list the pros and cons of a behaviour May motivate change or may paralyse the person if the pros and cons are equally compelling So - brief intervention does not always work due to patients ambivalence or resistance to change move to motivational interviewing

Motivational interviewing how to encourage behaviour change in the face of ambivalence and resistance Goal to facilitate intrinsic motivation rather than impose external reasons to change Particularly useful for people in pre-contemplation or contemplation stages

Resistance to change
a normal process to maintain familiar pattern rather than face change patient minimises risks/harm related to the behaviour Signs of patient resistance
Deflects - rationalises yes, but Projects - blames others Rebels argues, challenges, disagrees, becomes hostile Resigns unwilling to try, defeated

Key concepts resistance motivation ambivalence self-efficacy

Encountering resistance indicates need to change approach

Our influence on resistance to change Doctors can increase resistance by

Repeatedly advising behaviour change - nagging Taking an expert stance directive Confrontation or argument
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Ambivalence
Definition the simultaneous presence of two opposing ideas, attitudes or emotions e.g. love.hate it helps me.it harms me it relieves my stress.it creates stress Highlighting and resolving area of ambivalence can assist process of change

Doctors can reduce resistance by

To draw out areas of ambivalence

Encouraging patient to explore own motivations reflective

Motivation Motivation can be internal and external

Internal - indifference, obligation, autonomy External positive and negative incentives, barriers, supports Autonomous motivation tends to lead to sustained behaviour change Obligation or externally reinforced motivation tends to lead to less sustained change Indifference behaviour change unlikely

Self-efficacy Definitionconfidence in own ability to achieve a goal such as behaviour change High self-efficacy = I can do it
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Motivational interviewing aims to help patients develop this confidence and autonomy

Strategies for motivational interviewing: GRACE

Generate the gap raise awareness of ambivalence Roll with resistance listen, affirm, summarise Avoid arguments non-confrontational, reflect, ask for patient ideas Can do find evidence of previous success, change to improve self-efficacy, elicit self-motivational statements Express empathy understand ambivalence, respect persons decisions, be non-judgemental

e.g. safe sex behaviour in an adolescent find the ambivalence

RESISTANCE to CHANGE what do you like about not using condoms? 1. Benefits of not using condoms - shows I trust my partner - my partner will be more likely to stay with me - more spontaneous, enjoyable 3. Concerns about using condoms - partner doesnt like them - he might assume I have an STI 4. Benefits of using condoms - safe - shows he is taking some responsibility MOTIVATION to CHANGE what dont you like about not using condoms 2. Concerns about not using condoms - risk of STI - risk of pregnancy

Can be done within 5-10 minutes

- makes me feel dirty

Possible phrases Summarise to highlight ambivalence develop discrepancy

So you trust your partner but you are still worried about STIs Sex is more enjoyable but you are worried so it reduces the enjoyment Which concerns and benefits best fit your personal values?

Possible phrases Response to resistance avoid expert response

Patient yes, but I cant use condoms now that we havent been before Response I can see your dilemma here (empathic rather than well you know you are putting your health at risk logic has little impact) or you may decide to continue not using condoms for now

Possible phrases Avoid argument seek patients ideas

Do you have any ideas about how to resolve your dilemma? What might you do? Can you see any link between your dilemma about whether to use condoms and your current relationship problems?

Support self-efficacy
How would you rate your ability to change at the moment? (out of 10, where 10 is highly likely) Anything above 2 I am sure you are right, I can help you whenever you are ready