Motivating People for Behavior Change

1. Motivating People for Behavior Change Christine Fiore, Ph.D., University of Montana Department of Psychology October 19, 2007 Billings, MT

2. Motivational Interviewing - • Introductions • Hopes & Limitations • Background of Participants/Settings you work in • Amount of contact time with students/clients • Experience with Stages of Change/Motivational Interviewing?

3. Exercise : Persuasion • Select a behavior topic you are familiar with from your own work or yourself (acquiring GED, ESL classes,exercise, etc.) • Spend 1 minute with the person to your left explaining the reasons to adopt the behavior. Convince them! • Switch Roles • What did it feel like in each role?

4. Video: Chris Butler • This is NOT Motivating for this patient. • What is problematic here? • What is happening in their relationship? • What is Chris attempting to do in his physician role? • What is the patient communicating?

5. What Doesn’t Work? What does? • What have you discovered as problematic in your working relationships? • How do you know when things are not working? • How do you know when things are working? • Problems: • Downloading Information • Issuing Recommendations (Marching Orders) • Lost in a Forest of Behavioral Recommendations • Perceptions of “Compliance” • Avoidance • Others?

6. Exercise TWO: Expectations • Think of one person who you “dread” coming in to see you. • What thoughts come to mind about the person (why the dread?)? • What are your specific feelings about working with the person? • What approach do you take to imparting information with this person? • How would you describe your relationship? • Write down your answers and consider this person through the next section

7. Harnessing Motivation We often are assigned roles or tasks without the assistance of knowing ‘how to’ manage those who don’t ‘just do it’. We are not given the knowledge or tools to work with people who don’t want what we have to offer or are not ready to do what is required to succeed. We miss opportunities! Theories of motivation can provide us the framework for motivating people to change-

8. Change as a Process • Transtheoretical Model of Behavior Change (Prochaska & DiClemente, 1984) • Not “Just Do It” • Studied ‘Self-changers’, those who sought help in psychotherapy • Studied and applied now to a large number of behavioral health areas

9. Areas of Application TTM • Domestic violence • Eating disorders • Diet • Exercise • Chronic disease areas: diabetes, heart disease, etc. • General behavior change • Smoking cessation • Addictions • Sunscreen use • Mammography • Organ donation • Condom use • Delinquency

10. Discoveries • Change is a process. • Change is HARD. • Most of us attempt change but return to our old ways. • We do learn something from every change attempt- • The changing process is a learning process;it is not just about failing.

11. Discoveries • We (others) can’t make people change no matter how hard we try. • We can be helpful. • We can also make it less likely that someone will change. • We have learned some keys to this process.

12. The Transtheoretical Model (Readiness Model) • Stages • Process (Strategies) • Decisional Balance (Pros & Cons) • Self-efficacy (Situational Confidence)

13. Stages of Readiness for Change • Precontemplation-Not ready for change • Contemplation-Thinking but not doing • Preparation-Preparing but not quite ready • Action-Taking action and doing • Maintenance-Maintaining change for 6 months or more. • These stages are dynamic, moving, and represent varying levels of motivation for change (see handout)

14. Precontemplation • Not Ready for Change • Do not consistently show the desired behavior • Really have no intention of doing so

15. Precontemplation Stage • What Do we know about Precontemplators? • Characteristics: • Can’t , unable or unwilling to change • Lack awareness • Denial • Demoralized

16. Contemplation • Think About Changing. • Do not consistently commit to change. • Intend to do so in next 6 months

17. Contemplation Stage • What Do We Know About Contemplators? • Characterisics: • Ambivalent about change • Think maybe they should change • Don’t want to change

18. Preparation • Ready To Change • Still not entirely consistent-testing and getting ready for change • Intend to in next 30 days

19. Preparation Stage • Characteristics: • Ready for change • Have a plan • Committed to change • Most will attempt change in next 6 months but fail • Experiment

20. Action • Ready for Change and taking action • Consistently making an effort to do so • Less than 6 Months

21. Action Stage • Characteristics: • Making the changes • What ever they are doing works for them • Very busy time • Very unstable and hard stage

22. Maintenance • Adopted Behavior Change: • Consistently doing so • 6 months or more

23. Maintenance Stage • What do We Know about Maintainers? • Characteristics: • Risk of relapse low (unless stress) • Dynamic stage • Stable stage • Stayed in action for more than 6 months

24. BREAK • 15 minutes

25. Processes or Strategies for Change • Interact with stage: people use different processes at different stages for change • These strategies help people to move to the next stage; • Others may use strategies that cause people to keep holding hard onto the current behavior .

26. Decisional Balance • Pros and Cons to Change • Important to movement out of early stages • Vary with Stage: • Earlier stages (PC, C) report and feel more cons to change than pros • Later stages (A, M) report and feel more pros than cons • Preparation people are on the fence.

27. Decisional Balance Tells Us: • Discover what the pros and cons to change are! • Early stage: • Acknowledge the Cons- they are powerful • What makes them so? Curious? • Don’t argue or persuade anyone that they are not. • What about them Pros?

28. Pros • Early Stage: Not as powerful as cons • Accept this and discover why not-be curious. • Pros gain power as cons loose them-but you have to let people or yourself let cons go-none can take them from you! • Later stage people can envision or feel the pros-they can take hold and WIN!

29. Self-efficacy • The situational confidence (or lack of temptation) about a behavior • NOT self-esteem • Early stage (PC, C) low confidence-high temptation • Later Stage (A, M) high confidence-low temptation • Very important for movement into action and maintenance-HOPE

30. Self-efficacy tells us: • We need to instill and find hope. • We need to explore what would build confidence. • We need to explore and address what makes one tempted to return to the previous behavior/situation.

31. Putting it all together • Understanding change means understanding how the change process works within us and those we care about. • We are most helpful when we work with the process not against it.

32. What is Motivational Interviewing? • An application of the transtheoretical model of behavior change. • Emphasizes intrinsic motivation, personal empowerment and humanistic principles in it’s approach. • Backbone is counseling and communication skills applied in a strategic method. • Believes in the importance of adopting the philosophy of change in which spirit is connected to technique

33. Motivational Interviewing • Expects that relationship matters in facilitating change • Requires a shift in role from expert to facilitator • Considers that both student/client and teacher/counselor have agendas that are meaningful and important • Utilizes principles of change to facilitate movement • Respects that control of outcomes resides with the student/client

34. 5 Principles of MI: GRACE • G - Create a Gap • R - Roll with resistance • A - Avoid Arguing • C - Can do attitude • E - Express empathy

35. Create a Gap • A gap is a motivating discrepancy • Discrepancy comes from within the student • Good topics: where I want to be and where I am • Students present arguments for change • Goal - elicit and reinforce change statements

36. Roll with Resistance • Resistance is energy • Opposing resistance strengthens it • If resistance increases, change strategies • Offer new perceptions, don’t impose or argue them • Use the student as a resource for finding solutions

37. Avoid Arguing • Key to effective MI: keep resistance low • Student resistance influenced by teacher behavior • Across behaviors-the more confrontation, the more work avoidance, more drinking, eating • Avoid arguing for change • Acceptance of label (obese, alcoholic), unnecessary for change

38. Can do attitude • High self-esteem unnecessary • Without Can Do, risk turns to defensiveness • Impart belief that change is possible • The person will choose change, not you

39. Express Empathy • Create safety to explore conflicts and face reality. • Use non-possessive warmth, accurate understanding, and unconditional positive regard. • Opposite of breaking through denial • Acceptance facilitates change, pressure blocks it

40. Lunch- • Be back at 12:30 • Please be back promptly! • Afternoon: Motivational Interviewing Skills • Return: Thoughts? Questions?

41. VIDEO Rounder • Note in this intake setting example what Theresa Moyers does. • What is the response of the client? What is he doing? • What does she accomplish?

42. MI “Microskills” – OARS • Skills that you probably have already, but may not use very much • Helping roles may lead us to tell people what to do instead of work with them • Essential to good rapport • Basic skills we can use when we feel stuck • Backbone of MI

43. MI “Microskills” – OARS • Open-ended Questions • Affirmations • Reflective listening • Summaries

44. Open-ended Questions • Sets the tone for MI work • Creates momentum • Focus broadly • Key question : “What would you like to focus on today?” “What are you ready to address about your in your education?” • Rule of thumb: Use more reflections the more resistance you perceive

45. Affirmations • Some students are demoralized • Orients people to their resources • Be genuine • Probe partial successes • Reframe resistance into an affirmation • What and how questions are helpful

46. Reflective Listening • MI is built on this skill • Need to think reflectively • Levels of reflection: simple, reframe, and affective • Other types: two-sided, amplified • Vary your depth if you can but any reflection will improve working relationships most of the time

47. Summaries • Special form of reflective listening • Structure: • Indicate you’re about to summarize • Be selective • Note ambivalence & attend to change statements • Be concise! • End with invitation • Use to change directions or ask a key question

48. Exercise Three-Virginia Reel • Two Lines • One line Talkers • Other line reflectors (listeners) • Move on down as directed • PRACTICE • Talk about something you personally are working on changing or act a common student • Before moving on to the next person, summarize what you heard the person tell you

49. Change Statements & Change Talk • Problem Recognition? • Do they see the need to change? • Concern about Problem • Are they expressing interest and concern? • Intention to Change • Do they show readiness for change? • Hope about Change • How hopeful are they about changing?

50. Working with With Ambivalence • Ambivalence is a natural part of the change process • Just can not decide-fence sitting • There are positive things about adopting the behavior (pros to change) • There are negative things about adopting the behavior (cons to change) • Pros and Cons to change are important. • How one looks at them can become the key shifting point to ACTION • Explore Pros; Acknowledge Cons