9/20/2016 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
9/20/2016 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. 2
9/20/2016 Social Cognitive Theory (Bandura, 1986) Social Cognitive Theory (Bandura, 1986; Ashford, Edmunds, & French, 2010) Factor Intervention Vicarious experience of “similar other.” Self-efficacy 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 3
9/20/2016 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. Implementation intentions (“if - then”). Self-control 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. 4
9/20/2016 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) 5
9/20/2016 Foundations of Motivational Interviewing (Miller & Rollnick, 1991) Collaboration Patient is the expert. (vs. Confrontation) Patient-provider relationship is built on partnership. Evocation Patient has resources and motivation to (vs. Education) change. Provider must evoke. Autonomy Patient has right and capacity for self- (vs. Authority) direction. Provider respects and affirms this. Key Principles of Motivational Interviewing Principle Purpose Examples “Yes, making changes in hard work.” Express Build rapport and trust. “That must have been very challenging empathy for you.” “Tell me some good things and some Develop Patient identifies not-so- good things about X.” discrepancy reasons for change. “How does X fit in with your goals?” “It is your decision whether or not you Roll with Avoid power struggle/ want to quit.” resistance arguing for change. “What do you want to do? Where do Preserve rapport. you want to go from here?” Freedom of choice. “You have made some real progress.” Support Patient is responsible for “You have put a lot of thought into X.” self-efficacy carrying out change. 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
9/20/2016 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 2 Not Changing 1 Changing 3 4 7
9/20/2016 Decisional Balance Example: Increase Physical Activity Advantages Disadvantages More stressed One less thing to Can’t play with Not think about grandkids More time to watch Changing Worry more about TV health Easier More energy Buy equipment/gym Changing More self-confidence membership Sleep better Time commitment Increase strength 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 Example Technique “What kinds of things happened while Elicit negative consequences of not changing (engaging in problem behavior) that you later regretted? “I’m concerned about how X is contributing Express concern to your (health problem).” Offer information (don’t force!) “Would you like more information about the effects of X on your health?” “I understand you aren’t ready to work on Support and follow-up this yet. I’d like to check in with you about this again at your next appointment if that’s okay.” 8
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