values-based motivation for behavioral change in patients with … · 2016-09-27 · values-based...
TRANSCRIPT
Values-Based Motivation for Behavioral Change in Patients with
Chronic Illnesses
Michelle A. LeRoy, Ph.D., L.P.
Clinical Psychologist
Mayo Clinic Health System – Red Wing
26th Annual MNACVPR State Conference
October 7, 2016
Objectives
• Describe two theoretical models of health behavior change that can guide conversations with patients with chronic illnesses;
• Discuss the role of motivational interviewing in promoting health behavior change and increasing treatment adherence and self-management;
• Describe how motivational interviewing can be used to help patients identify discrepancies between deeply held beliefs/values and current problematic behaviors to move patients toward change.
Theories of Behavioral Change
• Transtheoretical Model • Social Cognitive Theory • Health Belief Model • Social Ecological Model
Transtheoretical Model (Prochaska, DiClemente, & Norcross, 1992)
Transtheoretical Model (Prochaska, DiClemente, & Norcross, 1992)
Transtheoretical Model (Prochaska, DiClemente, & Norcross, 1992)
Stage Intervention
Precontemplation Build rapport and trust.
Express non-judgmental concern.
Emphasize importance of seeing you again.
Contemplation Normalize ambivalence.
Elicit reasons for change.
Gently point out discrepancies between values and actions.
Preparation Acknowledge decision to make change.
Affirm ability to make change and identify what has worked in past.
Help set appropriate, achievable goals.
Action Encourage and support small steps toward change.
Acknowledge uncomfortable aspects of change.
Explain that “slips” should not disrupt the patient-provider relationship.
Maintenance Anticipate difficulties to help prevent relapses.
Recognize patient’s struggle and praise patient’s resolve.
Connect changes back to values.
Relapse Explore meaning of recurrence as a learning opportunity.
Commend any willingness to reconsider positive changes.
Support self-efficacy so that changes seem achievable.
Social Cognitive Theory (Bandura, 1986)
Social Cognitive Theory (Bandura, 1986; Ashford, Edmunds, & French, 2010)
Factor Intervention
Self-efficacy Vicarious experience of “similar other.”
Help set realistic and achievable goals.
Give feedback on performance.
Verbal persuasion.
Identify barriers.
Outcome expectations Ask about perceived consequences of behavior change.
Encouraging activities most likely to lead to desired
outcome.
Self-control Implementation intentions (“if-then”).
Reinforcements Patient sets planned rewards for self.
Pleasant experience in clinic, provider praise.
Emotional coping Education about coping/stress management skills.
Refer to Behavioral Health if appropriate.
Observational learning Lead by example.
Group intervention to learn from others.
Outcome Expectations for Exercise Scale (Wojcicki, White, & McAuley, 2009)
Physical outcome expectations
Exercise will improve my ability to perform daily activities
Exercise will improve my overall body functioning
Exercise will strengthen my bones
Exercise will increase my muscle strength
Exercise will aid in weight control
Exercise will improve the functioning of my cardiovascular system
Social outcome expectations
Exercise will improve my social standing
Exercise will make me more at ease with people
Exercise will provide companionship
Exercise will increase my acceptance by others
Self-evaluative outcome expectations
Exercise will help manage stress
Exercise will improve my mood
Exercise will improve my psychological state
Exercise will increase my mental alertness
Exercise will give me a sense of personal accomplishment
Social Cognitive Theory (Bandura, 1986; Ashford, Edmunds, & French, 2010)
Factor Intervention
Self-efficacy Vicarious experience of “similar other.”
Help set realistic and achievable goals.
Give feedback on performance.
Verbal persuasion.
Identify barriers.
Outcome expectations Ask about perceived consequences of behavior change.
Encouraging activities most likely to lead to desired
outcome.
Self-control Implementation intentions (“if-then”).
Reinforcements Patient sets planned rewards for self.
Pleasant experience in clinic, provider praise.
Emotional coping Education about coping/stress management skills.
Refer to Behavioral Health if appropriate.
Observational learning Lead by example.
Group intervention to learn from others.
Changes in home/work environment.
Behavior Change Considerations
Behavior change is a process, not an event. • Episodic vs. lifestyle • Gradual vs. abrupt • Restrictive vs. additive • Single vs. multiple
Objectives
• Describe two theoretical models of health behavior change that can guide conversations with patients with chronic illnesses;
• Discuss the role of motivational interviewing in promoting health behavior change and increasing treatment adherence and self-management;
• Describe how motivational interviewing can be used to help patients identify discrepancies between deeply held beliefs/values and current problematic behaviors to move patients toward change.
Motivation is...
• Multidimensional • Dynamic • Modifiable • Influenced by social interactions • Influenced by provider
Resistance Ambivalence Motivation
Traditional Medical Model
Confrontation Patient is impaired, unable to
comprehend situation.
Provider imposes reality.
Education Patient lacks knowledge.
Provider to enlighten.
Authority Patient lacks self-direction.
Provider instructs patient what to do.
Motivational Interviewing (Miller & Rollnick, 1991)
• Directive, patient-centered style of eliciting behavior change by helping patients explore and resolve ambivalence.
• Motivational interviewing outperforms
traditional “advice-giving” in the treatment of lifestyle problems and disease. (Rubak et al., 2005)
Foundations of Motivational Interviewing (Miller & Rollnick, 1991)
Collaboration (vs. Confrontation)
Patient is the expert.
Patient-provider relationship is built on
partnership.
Evocation (vs. Education)
Patient has resources and motivation to
change.
Provider must evoke.
Autonomy (vs. Authority)
Patient has right and capacity for self-
direction.
Provider respects and affirms this.
Key Principles of Motivational Interviewing
Principle Purpose Examples
Express
empathy
Build rapport and trust. “Yes, making changes in hard work.”
“That must have been very challenging
for you.”
Develop
discrepancy
Patient identifies
reasons for change.
“Tell me some good things and some
not-so-good things about X.”
“How does X fit in with your goals?”
Roll with
resistance
Avoid power struggle/
arguing for change.
Preserve rapport.
Freedom of choice.
“It is your decision whether or not you
want to quit.”
“What do you want to do? Where do
you want to go from here?”
Support
self-efficacy
Patient is responsible for
carrying out change.
“You have made some real progress.”
“You have put a lot of thought into X.”
Objectives
• Describe two theoretical models of health behavior change that can guide conversations with patients with chronic illnesses;
• Discuss the role of motivational interviewing in promoting health behavior change and increasing treatment adherence and self-management;
• Describe how motivational interviewing can be used to help patients identify discrepancies between deeply held beliefs/values and current problematic behaviors to move patients toward change.
Explore Goals and Values • Use open-ended questions
• What were some times in your life when you were happiest or most proud/fulfilled/satisfied?
• What makes that important to you? • How does that give your life meaning? • What are your hopes for the future? • Imagine your life 5 or 10 years in the
future if you were to continue on the same path without making any changes. Now imagine your life 5 or 10 years in the future if you were to make changes. What are the differences?
Decisional Balance
• To change, the scale needs to tip so that the benefits outweigh the costs
• Explore/Elicit
• 1. Advantages of NOT changing • 2. Disadvantages of NOT changing • 3. Disadvantages of changing • 4. Advantages of changing
Decisional Balance
Advantages Disadvantages
Not
Changing
Changing
1
2
3 4
Decisional Balance Example: Increase Physical Activity
Advantages Disadvantages
Not
Changing
Changing
One less thing to think about More time to watch TV Easier
More stressed Can’t play with grandkids Worry more about health
More energy More self-confidence Sleep better Increase strength
Buy equipment/gym membership Time commitment Don’t like it
Readiness Ruler
• On a scale of 0 to 10, how ready are you to change X?
Score Readiness Stage of Change
0-3 Not ready Pre-Contemplation
4-7 Unsure Contemplation
8-10 Ready Preparation; Action
Readiness Scores 0-3 Motivational Interviewing
Technique
Example
Elicit negative consequences
of not changing
“What kinds of things happened while
(engaging in problem behavior) that you
later regretted?
Express concern “I’m concerned about how X is contributing
to your (health problem).”
Offer information (don’t force!) “Would you like more information about the
effects of X on your health?”
Support and follow-up “I understand you aren’t ready to work on
this yet. I’d like to check in with you about
this again at your next appointment if that’s
okay.”
Readiness Scores 4-7
Motivational Interviewing
Technique
Example
Elicit motivation to change “Wow, you said 6 out of 10. What
made you say 6 instead of a 2?”
“What would need to happen to get
your up to an 8?”
Negotiate a plan “What ideas do you have to start X?”
Support and follow-up “I’m really impressed that you’ve
decided to take this next step. I’d like
to check back with you in two weeks
to see how it’s going.”
Readiness Scores 8-10
Motivational Interviewing
Technique
Example
Help develop action plan “Let’s look at the steps necessary to
help you X. What would be your first
step?”
Identify resources “Who has been supportive of you
before? How can that person help
you X”
Instill hope “You’ve been successful with Y, so
you have the ability to X.”
References Ashford,S., Edmunds, J., & French, D.P. (2010). What is the best way to change self-efficacy to
promote lifestyle and recreational physical activity? A systematic review with meta-
analysis. British Journal of Health Psychology, 15 (2), 265-288.
http://dx.doi.org/10.1348/135910709X461752
Bandura, A. (1986). Social Foundations of Thought and Action. Englewood Cliffs, New Jersey:
Prentice-Hall.
Miller, W. R. and Rollnick, S. (1991). Motivational interviewing: Preparing people to change
addictive behavior. New York: Guilford Press, 1991.
Prochaska, J.O., DiClemente, C.C., & Norcross, J.C. (1992). In search of how people change:
Applications to the addictive behaviors. American Psychologist, 47, 1102-1114.
PMID: 1329589
Rubak, S., Sandbæk, A., Lauritzen, T., & Christensen, B. (2005). Motivational interviewing: a
systematic review and meta-analysis. The British Journal of General Practice,
55(513), 305–312.
Wójcicki, T.R., White, S.M., & McAuley, E. (2009). Assessing outcome expectations in older
adults: The multidimensional outcome expectations for exercise scale. Journal of
Gerontology: Psychological Sciences, 64B(1), 33–40, doi:10.1093/geronb/gbn032