3. Changing behaviours:
The usual consultation – Where is the problem?
-Up to 50% of non adherence for medical treatments in chronic conditions
(HT, Cholesterol, DM2)
-DM patients refer suffering and revolt due to restrictions imposed by
diet, physical activity and medication.
-Difficulties for counselling in Primary Care: expectancies (“people want
treatments, doctors want success)”; lack of training…(DEmack1987)
-Doctors think that 3 most important CVRF (tobacco /HT / Chol) can be
modified, but have low confidence in their ability to influence them –
specially tobacco (Mann 1989)
4. Exercise:
Pairing with your colleague, identify any type of
barriers /difficulties for change in this consultation (barriers
from the patient, from the doctor, from the encounter...)
2min.
(We are not going to use them, the exercise is just to make a
reflection on it!).
5. GP- Let´s talk about things we can try: diet and exercise. What about diet?
P – Well, for me is difficult because when I feel anxious -I recognize- I eat a lot. It is
difficult for me to control myself.
GP – In that case you must try, at least, to eat low-fat meals.
P – Yes, but it is difficult when you have to have meals outside!
GP- And what about exercise? Can you try to do some more exercise?
P – Oh, yes, I like walking, but I have almost no time for it…
GP – You can try a little everyday…we consider it is enough 20 -30 min walking.
P – Yes, but…when I finish lunch, I have to come back to work. And in the evenings, I
feel so tired that I don’t want to go for a walk…what I really like is watching TV or
having a beer with friends
GP – Yes. But it is necessary for you, if you want to prevent cardiovascular diseases, as
you told me. We must do something about this.
P – Yeees but…I understand, I am worried about it, but it seems difficult for me now. I
try my best but…
6. Some theories to explain usual health behaviour
Protection Motivation Theory:
“A person tends to protect him or herself from a emergent risk
if the threat is harmful and severe, if the behaviour advocated
is seen as effective and achievable (few barriers) and if there
is little benefit in a maladaptive behaviour”
7. Some theories to explain usual health behaviour
“Extended Parallel Process Model”:
When there is a threat, a person first assesses severity and
susceptibility of the health threat. If these are perceived as
low, one will cease to process the message. If perceived as
high, then one assesses self-efficacy and response efficacy of
the solution being offered
8. Some theories to explain usual health behaviour
“Theory of Planned Behaviour”:
Intentions to perform a behaviour can be predicted from:
Attitudes toward the behaviour
Subjective norms (“what others think”)
Perceived behavioural control (self –efficacy)
Individuals weigh their own attitudes against their
perceptions of others’ attitudes. If there is discordance, they
decide how to behave based upon costs and benefits.
9. Some theories to explain usual health behaviour
“Cognitive Dissonance Theory”:
It focuses on the relationship among cognitive elements
(beliefs, opinions, attitudes, knowledge) , which can be
consonant or dissonant to each other.
Individuals tend to reduce psychological discomfort (produced if the
Dissonance is of a strong magnitude) by changing / adding consonant
cognitions, or changing its importance.
When reducing dissonance, one tends to use the easiest way
M I attempts to create dissonance within the patient, which is
then used to encourage the patient to consider pros and cons
of behaviour
10. Why do people change?
How do people change?
Change occurs naturally Treatments facilitate the natural process
of change; formal interventions imitate natural change
Brief Interventions Effects: A little counselling can lead to
significant change
Dose Effects: Brief interventions as effective as longer ones.
Hope: people who believe that they are likely to change, do so.
Counselor effects: characteristics of therapist associated with
success in treatment (empathy). This style is manifested early in treatment.
12. Willingness/ importance
Ability/ how to do it, solutions
Readiness / priorities
-All these three elements can be sources of the “yes but…”
dilemma, which is a manifestation of ambivalence
-People usually get stuck by this inner contradictions, they
feel two ways about it (ambivalence)
-To make change effective and possible, people need to
explore their contradictions (between present behavior and
future outcomes or desires), and to connect it with something
valuable and important.
13. What could “diet” mean?
• Imagine that your family physician have just
diagnosized you a diabetes and tells you to do a diet:
6 meals a day, low fat and no rapid
absorption carbohydrates
• Brain storming sharing with your neighbour what
ideas and feelings appear in your mind when you
think about this diet and your life.
Just one or two words for each idea without explanation.
1 minute
14. What could “diet” mean?
Restrictions
Dominated
by diabetesNot enjoying
meals
Eat without apetite
Apetite and not to eat
Health
No change
Better control
Difficulties
Being fit
15. Ambivalence
No change
Ideas and feelings about:
positive aspects of present
behaviour
negative aspects of new
behaviour
Change
16. Ambivalence
No change
Ideas and feelings about:
positive aspects of present
behaviour
negative aspects of new
behaviour
Difficulties of changing
Change
Ideas and feelings about:
negative aspects of
present behaviour
17. Ambivalence
No change
Ideas and feelings about:
positive aspects of present
behaviour
negative aspects of new
behaviour
Difficulties of changing
Change
Ideas and feelings about:
negative aspects of
present behaviour
positive aspects of new
behaviour
18. What happens with ambivalence when we give advice?
We place ourselves in the change side of ambivalence
We tell the patient what to do
“Psychological reactance”.
Yes, but …
The position of the patient is in part the result of a lot
of advices they have listened to.
19. What is the problem if the patient tells aspects against changing?
• Self perception theory (Bem):
We believe in what we say.
• It is difficult for me to control myself.
• It is difficult when you have to have meals outside!
• I have almost no time for it.
• When I finish lunch, I have to come back to work. And
in the evenings, I feel so tired that I don’t want to go
for a walk.
21. Change-Talk Effects
What people say about change is important:
-Statements that reflect motivation /commitment to
change do predict subsequent behaviour
-Arguments against change (resistance) make it less likely
to occur
-Both types of talk can be influenced by the counsellor.
22. Changing talk
– Needs
I can´t breath.
– Reasons
If I reduce my weight I will have less pain in my knees.
– Desires
I wish I could control my appetite.
– Abilities
I did it before.
25. Motivational interviewing
Is a collaborative guiding method,
person centered,
to elicit and strength motivation
to change.
Guiding ≠ directing ≠ following
Working with their ideas and targets
Motivation is built with their ambivalence
We work in the way of improving their health
26. The basis of motivational interviewing
• Listen to your patient
– Solutions are inside them.
• Understand your patient motivations
– Only their arguments could move them.
• Resist the “righting reflex”
– When we try to correct we generate resistance.
• Empower your patient
– Is the one that is going to make the effort.
28. Results comparing MI
Lundahl B, Burke BL. The effectiveness and applicability of
motivational interviewing: a practice-friendly review of four
meta-analyses. J Clin Psychol. 2009 Nov;65(11):1232-45.
Targeted outcomes included:
• Substance use (tobacco, alcohol, drugs, marijuana)
• Health related behaviors (diet, exercise)
• Engagement in treatment variables
29. Results comparing MI
• Lundahl B, Burke BL. The effectiveness and
applicability of motivational interviewing: a
practice-friendly review of four meta-analyses.
J Clin Psychol. 2009 Nov;65(11):1232-45.
Group of comparison Effect size
(1=standard
deviation)
CI p
Weak
(Waiting list, treatment as
usual, written materials )
0.28 0.22-0.34 <0.001
Strong
(12-step program or
cognitive behavioral
therapy)
0.09 -0.01-0.18 0.080
30. What for?
Sune Rubak, Annelli Sandbæk, Torsten Lauritzen and Bo Christensen. Motivational interviewing: a
systematic review and meta-analysis. British Journal of General Practice, 55: 513, pp. 305-312
32. What can we do in ten minutes?
. Ask open-ended questions
. Listen with empathy
. Understand the patients’ motivations
. Elicit change talk
…and in a little more time, maybe some other day…
. Hear a commitment?
. Help in a change plan?
. Agree the follow-up plan?
. Prevent relapse/supervise change behaviour?
33. Four strategies(OARS)
. Ask Open-ended questions
. Affirm the patient
. Do Reflective listening
. Make Summaries
34. Open-ended questions
. What is your behaviour like?
. How do you feel about it?
. What happened/could happen when you/if you tried to?
. Which advantages/disadvantages do you see in…?
. How important is it to you?
. What should happen that would make you consider a change?
. Understand (with empathy) the patients’ motivations
. Elicit change talk
35. Affirmation
. Listen carefully to what the patient says: they may have succeed, they may have
strong abilities, they may be willing to change, they may have a good plan, they may
know what it’s all about…
Tell them!!!
…it really empowers your patient…
36. Reflective listening
. Try to evoke their reasons, their abilities, their desires, their needs, maybe their
commitment…
Pick up the flowers and give them!!!
…that’s the energy that’s going to make them move…
37. Summaries
. Put all the information together, it will help you to clarify and understand your patient
better, and give it back
…then ask what now?
…it may lead them to move forwards…
38. And then…?
. Agreeing a change plan and a follow-up must be done with the same collaborative,
evocative and autonomy supportive spirit
…and if relapse occurs?
…more of the same: “normalize”, listen with empathy, try to understand, ask for the
next step and leave the door open!
39. What about feedback?
. Giving information is sometimes useful, it may give the patient reasons and needs to
change…but first knock on the door!
…and all those scales and rulers,
how do I use them?
. They are a good way to elicit change talk; you can ask how willing the patient is,
how confident, which degree of commitment…
40. Getting back to reality…
. Very often we have…
.. Other matters to talk about
.. More than just one target behaviour
.. Less time than we would like
. What if I’m tired?
. First agree an agenda
. Let them choose which target behaviours are affordable
. We are in primary health care: we always have time to meet again or choose
another day!
Editor's Notes
DM patients refer suffering and revolt due to restrictions imposed by diet, physical activity and medication.several difficulties related to the treatment follow up,suffering and revolt due to restrictions imposed by the diet, physical activity and medication. It is possible to infer that the focus of the education approach should not be restricted to the transmission of knowledge; itshould also include emotional, social and cultural aspects that also influence in the treatment follow up.
If there is discordance, people decide how to behave based upon cost and benefits of ascribing more weight to either one´s attitude or attitudes of others
Individuals tend to reduce psycological disconfort (produced if the Dissonance is of a strong magnitude) by changing one element to make it more consonant, adding consonant cognitions, orchanging the importance of cognitions
It is also a useful question. We usually think that people don´t change; but change also occurs, even naturally, without treatments. These are brief statements about it
Hope: Perceived prognosis is a good predictor
Natural change: most people who quit smoking do so without assistnace
It is also a useful question. We usually think that people don´t change; but change also occurs, even naturally, without treatments. These are brief statements about it
Natural change: most people who quit smoking do so without assistnace
.Your doctor have diagnosized you a diabetes and tells you how you should eat. What ideas and feelings appear when you think in diet?
Let´s do a brain storming. Share with your neighbour some of this ideas and feelings.
Maybe some of this appeared. But also no change (imagine that at home you have a child with diabetes and everyone eat the same. Usually positive aspects are not remembered but they exist.
.Your doctor have diagnosized you a diabetes and tells you how you should eat. What ideas and feelings appear when you think in diet?
Let´s do a brain storming. Share with your neighbour some of this ideas and feelings.
Maybe some of this appeared. But also no change (imagine that at home you have a child with diabetes and everyone eat the same. Usually positive aspects are not remembered but they exist.
As we have seen, sometimes people doesn´t change their behaviour even if it´s necessary for them and our arguments doesn´t succeed to convince them.
Why does that happen?
First we are considering what happens when we give advice with our patient ambivalence.
As we are arguing in favour of one of the sides of ambivalence our patient will answer explaining why she or he has not changed yet, the reasons to stay as they are.
This is caused by psychological reactance. This term means that when people feel that their freedom to decide is frightened they oppose to that arguments.
Usually, after agreeing with the statements they have heard, a but introduces the ideas against them. That ideas could refer to their values, their feelings about what change supposes and their ability to afford it or even questioning the right that we have to give them that advice in that moment.
In some way the current patient position have been developed opposing other people arguments. Think of a smoker and how their relatives or friends advice influence their ideas. Maybe they agree with them but they become irritated or in bad mood.
What happens when the patient refers his o her reasons against changing as result of our advice?
In his Self perception theory, Bem explains something very simple: people use to believe what they say. If they hear themselves claiming that change is not interesting, very difficult or it is not what they really like they believe that as their own position.
It is very difficult to motivate yourself to do something that you are saying that you don´t desire.
When patients speak freely about a behaviour they are ambivalent they have to types of talk reflecting both sides of ambivalence. As we have seen sustained talk shows the reasons to stay as they are and the difficulties they see when they consider changing. On the other side they can talk about the positive aspects of changing.
For exemple
-
-
-
-
Some phrases show both sides.
It is also a useful question. We usually think that people don´t change; but change also occurs, even naturally, without treatments. These are brief statements about it
Natural change: most people who quit smoking do so without assistnace
Changing talk is about the needs, reasons, desires and abilities the patient have about changing his/her behaviour.
When patients hear themselves arguing the positive aspects of changing, including their abilities to afford it they become more motivated.
But when this changing talk have been analysed has no been predictive of behaviour change. Only when patient expresses statements that show commitment with change or starting to do small steeps changes is more probable.
If we see the amount of both change talk and sustained talk in people that at the end of the interview made a change plan and the ones that do not made it, in the beginning both types appear but if the patient reduce sustained talk and increased change talk then is more probable that change plan is made.
Motivational interviewing is a method that tries to enhance patient’s motivation considering this ideas.
Let’s see a definition:
Collaborative means that we work with the patient, guiding them in the way they are deciding.
I don´t think necessary to explain what people centered means here.
Elicit and strength motivation because the fuel of motivation is the patient ambivalence and motivation arises from their needs, reasons and desires considering their abilities to get his/her targets
Motivational interviewing is not neutral, we work in the way of improving our patients’ health.
As you could notice from the definition MI is very close to general practice.
Most of their basis respond to a patient centered model of clinical practice like listen to patients and understand their motivations. But also reflect that we are going to work with the words that we have listened and the arguments that they show.
The righting reflex is what mice do when we place them with their legs up, they inmediately turn down. And it is what we do when we see something wrong (think for example in what you feel looking to an inclined picture . We try to fix it. If we try to cure our patient behaviour we boost his/her resistance showed as sustained talk and lower probability of change. If we don´t show that we are desiring their change we avoid resistances and permit that both sustained and changing talk emerge.
The last point highlights the importance of reinforcing the self-image of a person in order to enhance his or her ability to afford the change.
Last slide just to explain that MI is very new and it is developing. If you try MI and MI and PC you get this numbers in groups of five years.
I would like to consider the results of this method. Lundhal and Burke have published the last methanalisis of MI. In it they have included studies about substance problems, health behaviour change and treatment adherence.
We can divide the comparison groups in the ones with a demonstrated efectivity and other not specific.
MI is equivalent in efectivity to the specific methods and better than usual care in a moderate way.
And is shorter in time that the specific methods compared.
