9/20/2016. Values-Based Motivation for Behavioral Change in Patients with Chronic Illnesses. Objectives. Theories of Behavioral Change

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1 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 26 th 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 1

2 Transtheoretical Model (Prochaska, DiClemente, & Norcross, 1992) Transtheoretical Model (Prochaska, DiClemente, & Norcross, 1992) Transtheoretical Model (Prochaska, DiClemente, & Norcross, 1992) Stage Precontemplation Intervention Build rapport and trust. Express non-judgmental concern. Emphasize importance of seeing you again. Contemplation Preparation Action Maintenance Relapse Normalize ambivalence. Elicit reasons for change. Gently point out discrepancies between values and actions. Acknowledge decision to make change. Affirm ability to make change and identify what has worked in past. Help set appropriate, achievable goals. Encourage and support small steps toward change. Acknowledge uncomfortable aspects of change. Explain that slips should not disrupt the patient-provider relationship. Anticipate difficulties to help prevent relapses. Recognize patient s struggle and praise patient s resolve. Connect changes back to values. Explore meaning of recurrence as a learning opportunity. Commend any willingness to reconsider positive changes. Support self-efficacy so that changes seem achievable. 2

3 Social Cognitive Theory (Bandura, 1986) Social Cognitive Theory (Bandura, 1986; Ashford, Edmunds, & French, 2010) Factor Self-efficacy Outcome expectations Self-control Reinforcements Emotional coping Observational learning Intervention Vicarious experience of similar other. Help set realistic and achievable goals. Give feedback on performance. Verbal persuasion. Identify barriers. Ask about perceived consequences of behavior change. Encouraging activities most likely to lead to desired outcome. Implementation intentions ( if-then ). Patient sets planned rewards for self. Pleasant experience in clinic, provider praise. Education about coping/stress management skills. Refer to Behavioral Health if appropriate. 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 3

4 Social Cognitive Theory (Bandura, 1986; Ashford, Edmunds, & French, 2010) Factor Self-efficacy Outcome expectations Self-control Reinforcements Emotional coping Observational learning Intervention Vicarious experience of similar other. Help set realistic and achievable goals. Give feedback on performance. Verbal persuasion. Identify barriers. Ask about perceived consequences of behavior change. Encouraging activities most likely to lead to desired outcome. Implementation intentions ( if-then ). Patient sets planned rewards for self. Pleasant experience in clinic, provider praise. Education about coping/stress management skills. Refer to Behavioral Health if appropriate. 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. 4

5 Motivation is... Multidimensional Dynamic Modifiable Influenced by social interactions Influenced by provider Resistance Ambivalence Motivation Traditional Medical Model Confrontation Education Authority Patient is impaired, unable to comprehend situation. Provider imposes reality. Patient lacks knowledge. Provider to enlighten. 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) 5

6 Foundations of Motivational Interviewing (Miller & Rollnick, 1991) Collaboration (vs. Confrontation) Patient is the expert. Patient-provider relationship is built on partnership. Evocation (vs. Education) Autonomy (vs. Authority) Patient has resources and motivation to change. Provider must evoke. Patient has right and capacity for selfdirection. 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 Support self-efficacy Avoid power struggle/ arguing for change. Preserve rapport. Freedom of choice. Patient is responsible for carrying out change. 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? 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. 6

7 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 Not Changing Changing Advantages 1 4 Disadvantages 2 3 7

8 Decisional Balance Example: Increase Physical Activity Not Changing Changing Advantages One less thing to think about More time to watch TV Easier More energy More self-confidence Sleep better Increase strength Disadvantages More stressed Can t play with grandkids Worry more about health 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 Elicit negative consequences of not changing Example 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. 8

9 Readiness Scores 4-7 Motivational Interviewing Technique Example Elicit motivation to change Negotiate a plan 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? 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 Identify resources Instill hope Let s look at the steps necessary to help you X. What would be your first step? Who has been supportive of you before? How can that person help you X You ve been successful with Y, so you have the ability to X. Questions/Comments? Contact: Michelle LeRoy, Ph.D., L.P. 9

10 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 metaanalysis. British Journal of Health Psychology, 15 (2), 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, Prochaska, J.O., DiClemente, C.C., & Norcross, J.C. (1992). In search of how people change: Applications to the addictive behaviors. American Psychologist, 47, PMID: 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), 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: /geronb/gbn032 10

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