Motivational Enhancement Strategies to Promote Healthy Behavior Change

Transcription

1 Motivational Enhancement Strategies to Promote Healthy Behavior Change Joseph H. Hinkebein Ph.D., ABPP Licensed Psychologist Health Behavior Coach My Challenge! Our Challenge! Health care providers often encounter patients who are their own worst enemies because of unhealthy behaviors and lifestyles. Medical advances in the treatment of many previously intractable conditions has inadvertently created a culture in which some believe there is a pill for everything. Some patients may resist the idea that changing lifestyle and behavior is critical to achieving better health and quality of life. 1

2 Our Challenge! Yet, many chronic health problems are tied to unhealthy lifestyle, and no amount of medical intervention can overcome the impact of poor lifestyle choices and behaviors. Our Challenge! Our Challenge! Helping our patients recognize and understand how an unhealthy lifestyle contributes to their health problems is an important part of our work. Effective education and health coaching can promote better health outcomes and improved quality of life, while reducing health care costs and unnecessary health care utilization. Yet, we have all encountered situations where it feels like we are working harder than the patient to achieve better health outcomes. This can lead to frustration, conflict, poor relationships with our patients, and ultimately clinician burnout. 2

3 Our Challenge! Topics to be Covered Stages of Change Model Health Belief Model Motivational Interviewing Health Behavior Coaching The Righting Reflex Dealing with Ambivalence Dealing with Fear Dealing with Resistance Change versus Sustain Talk Health Belief Assessment Honor the Patient When do people change? When they are able to identify their own reasons or motivations for changing And, the advantages of changing (or the cost of not changing) exceeds the disadvantages of changing (or the cost of staying the same). People seldom make permanent change in response to external pressures (in the absence of internal motivation). They either will refuse the course of action, or temporarily act until the external pressure is removed. This is particularly true if change is not perceived as personally important, or if ambivalence about change exists. 3

4 Stages of Change? Transtheoretical Model (Prochaska & DiClemente, 1983; Prochaska, DiClemente, & Norcross, 1992): Stages of Change Precontemplation: patient does not intend to take action in the foreseeable future. Being uninformed or under informed about the consequences of one s behavior may prolong this stage. Contemplation: Patient is more aware of the pros of changing, but are also acutely aware of the cons. Starting to wrap mind around the need for change. Preparation: Patient intends to take action in the immediate future and may have already taken some significant action to prepare for change. Stages of Change Action: Patient has made specific overt modifications in their lifestyles (example: has quit tobacco or alcohol) Maintenance: Patient has made specific overt lifestyle modifications and are working to prevent relapse. While in this stage, patient is becoming less tempted to relapse and become more confident that they can continue with the healthy changes they have made. Motivational Interviewing and Health Coaching can promote patient movement through the stages of change. 4

5 Health Belief Model and Change Chances that patients will make healthy change or to take recommended action increases if they perceive: Personal susceptibility to the health problem Health problem is likely to have serious consequences That the recommended actions are likely to be effective Taking action is less of a threat than having the health problem What can we do? We may need to challenge our own understanding of our role and responsibilities as a healthcare provider. Typically, healthcare providers are trained to diagnose and fix health problems. We have been socialized to be problem solvers. This works well with patients who are ready and motivated to hear and accept our prescribed fix (in contemplative or action stage) Some patients are receptive to (or compliant with) treatment recommendations, but we often encounter those who resist our treatment recommendations and guidance (precontemplative). How do you handle this resistance to treatment, in all its varied forms (ambivalence, fear, need for control, anger)? Motivational Interviewing? Definition: A clinical method of guiding patients to make changes in the interest of their health by eliciting patients own motivation for change. (Rollnick, Miller and Butler, MI in Health Care, 2008) A collaborative conversation style for strengthening a person s own motivation and commitment for change (Miller and Rollnick, MI: Helping People Change. 3 rd Edition 2013) 5

6 Motivational Interviewing? Motivational Interviewing strategies are: Patient centered Supports patient autonomy Collaborative, not directive Empowers patient for self management The Spirit of MI: Dancing vs. Wrestling Partnership The provider develops a collaborative atmosphere between experts; not coercive Recognizes that the patient will exercise choice. (Asking permission) Acceptance Partnering, collaborative style; non judgmental Expertise vs. expert Compassion The provider actively promotes the patient s welfare. He/she gives priority to the other s needs Evocation Exploring what is important to the patient; their ideas, needs, values and reasons for change Views patients as experts (in their own life) Ideally, the patient will be speaking more than clinician The Spirit of MI: Dancing vs. Wrestling Engaging: listening to understand, use of OARS* Focusing: agenda setting, finding a common and strategic focus, exploring ambivalence, use of information and advice Evoking: selective eliciting, selective responding, selective summaries toward change talk Planning: moving to a change plan and obtaining commitment 6

7 The Spirit of MI: Dancing vs. Wrestling *OARS? Open Ended Questions (can t be answered with a yes or no) Affirmations (builds confidence, reinforces past efforts) Reflections (conveys understanding, might reframe meaning) Summaries (brings information together in a meaningful way) The Spirit of MI: Dancing vs. Wrestling Open ended questions: Use these to help us understand patient s perspective and motivation. Affirmations: Use to recognize patient efforts and strengths. Also builds rapport. Reflections: Use these to help deepen insight and understanding, and also to elicit more information or contemplation in our patients. Also lets patient know they are being listened to and heard. Summary: Used to convey understanding, eliciting more contemplation of possible change, and to reinforce change talk (more on change talk later). Useful MI Mnemonic: RULE Resist the Righting Reflex (Resist Directing) Understand your patient s motivations (Evoke) Listen to your patient (with Empathy) Empower your patient (Build Confidence) When you encounter resistance: Stop and Reset Ask, Listen, Reflect and Evoke 7

8 The paradox! The Righting Reflex Sometimes the harder we work to overcome patient resistance, the stronger that resistance becomes. This phenomenon is known as the righting reflex. The righting reflex refers to the tendency for people to resist or push back against persuasion when they are ambivalent about changing or taking a particular course of action. So, given our powerful need to fix it, we amplify our efforts to persuade or cajole, leading to even more resistance. So what s a caring and compassionate health care provider to do?! Drop the rope! When caught in the righting reflex trap, it is like having a tug of war with our patient. The first thing to do (once you realize you are in a tug of war) is DROP THE ROPE! Drop the rope! For the moment, let go of the need to fix it, and instead seek to understand what is going on with the patient. Consider: as healthcare practitioners, we have an agenda for what we want to accomplish when we have a patient encounter (whether we know it or not). Do we take the time to find out what the patient s agenda might be? What is most important to the patient right now, may not be congruent with your agenda as a healthcare provider. 8

9 Don t assume. Seek to Understand Resistance occurs when our agenda and our assumptions about the patient s agenda are non congruent. Help me to understand add these words to your clinical repertoire! Mr. Smith, in today s appointment I would like to address your blood sugar control. But first, I would like to know what is most important to you today. What is your priority for today s appointment? Worst case scenario? You might discover your patient has different priorities than yours for today s appointment. However, this is important to know, and allows you to negotiate the agenda and assess for ways forward. Start with Relationship/Rapport It is difficult to have a meaningful discussion about lifestyle change or taking a course of medical action if a minimal foundation of trust has not been established. Patients come to us with a wide array of past experiences that have relevance to their potential receptivity to medical advice and lifestyle coaching. Relationship and Rapport What is helpful to know? Their living situation. Their past experiences with health professionals. Their personal preferences when it comes to making difficult medical decisions. What is are the most important things in the patient s life (values). What is the patient s vision of good health? Relationships that are relevant to the patient s lifestyle and medical choices. Other things? 9

10 Start with Relationship/Rapport If this is an established patient, check to see if there is anything new going on in their lives that might be interesting (and relevant). Knowing what is important to our patients (what is most important in their lives, values, supports) allows us to tailor our communication and recommendations to those realities. Health Coaching and MI? Advanced Practice Nurses should be encouraged to add health coach to their professional identity and skill set. Health Coaches use patient centered communication, health education and motivational interviewing strategies to have conversations about healthy lifestyle change and hopefully promote adherence to a healthier lifestyle. Health education and health promotion within a coaching context to enhance the well being of individuals and facilitate the achievement of their health related goals. (Palmer S, Tubbs I, and Whybrow A. 2003) Health Coaching Help patients: Clarify personal health goals Find their own reasons for changing lifestyle Implement and sustain healthy behaviors Reduce negative impact of chronic disease Guide patients in learning and practicing self management Develop skills to better manage health problems and improve well being. Learn problem solving skills to overcome obstacles to more effective self management of health problems 10

11 Health Coaching: Outcome vs. Process What makes for a successful health care intervention and outcome? Is it only when a patient agrees to change or take a recommended course of action? Have we failed when patients are not ready to change or follow our recommendations? This is a recipe for burnout! Health coaching and MI helps us avoid this trap. Health Coaching: Outcome vs. Process A successful health coaching intervention may not yield immediate change or willingness to follow medical advice, but it often helps lay the groundwork for eventual change. How? The patient has reflected on the possibility of change. The patient was encouraged to consider their own argument for change. The righting reflex has been avoided (the patient did not inadvertently make an argument for not changing) You have left open the door for discussing healthy change at a future time Health Coaching: Outcome vs. Process I am glad we talked about your smoking habit. I have a better understanding of what is most important to you right now, and why you are not yet ready to make a quit attempt. I obviously am recommending that you consider quitting, and I am ready to help you with quitting when you feel the time is right. With your permission, I would like to check in with you at your next appointment to see if any of the things we discussed today have changed. I know you can and will be successful when you decide the time is right to make another quit attempt 11

12 Crash Course in Health Coaching Step 1: Establish a positive relationship with the patient Develop a partnership with the patient Explain your role as a coach Step 2: Elicit the patient s concerns and issues Use active listening skills Express empathy Step 3: Set an agenda with the patient for this session You ve said you re concerned about several things,. What would you like to get out of today s session? Crash Course in Health Coaching Step 4: Connect the coaching topic to the patient s life goals and values Focus on the whole person, not just a specific diagnosis or behavior Step 5: Acknowledge the patient s likes, dislikes, preferences Empower the patient by reminding her that the choices are hers to make Offer to help the patient find the answers that will work best for him or her. Crash Course in Health Coaching Step 6: Ask before telling Ask what the patient already knows and what the patient wants to know Provide new information and clarify misperceptions as needed Invite the patient to consider a different perspective Confirm the patient s understanding 12

13 Crash Course in Health Coaching Step 6: Ask before telling An example from House MD Patient: My asthma they said they fixed it but it didn t make any difference at all. Dr. House: Well, sometimes doctors make mistakes. Crash Course in Health Coaching Step 7: Ask the patient how important he or she thinks it is to change. Perceived importance is key aspect of readiness to change Perceived importance may be situational On a scale of 1 to 10, with 1 being not important at all and 10 being very important how would you rate the importance for you of (making a particular change or taking a course of action?) Not Important Very Important Crash Course in Health Coaching Step 7 continued: Exploring perceived importance of change Importance > 7? Help me understand why you gave it this rating? Importance < 7 but > 3? What makes you give yourself a 5 instead of a 2? Both of the above strategies encourages patient to consider reasons and motivations for making a change. Importance < 2? What would it take (what would have to happen) to move your rating from a 1 or 2 to a 5? Gives insight into what might need to occur for motivation to change to increase. 13

14 Crash Course in Health Coaching Step 7 continued: To enhance importance: Provide information that may be new to the patient Point out discrepancies between the patient s values and life goals and current behavior Encourage the patient to think about the need for change Respect the patient s priorities and choices Express empathy Keep the door open offer support when the patient is ready Crash Course in Health Coaching Step 8: Help the patient set a goal/make an action plan. Ask the patient what she s already doing for her health Ask the patient to identify something he can do to improve his health Focus on behavior, not outcome Start small and build up over time Start with one week time frame Make it SMART (Specific, Measurable, Achievable, Relevant and Time Basd) Crash Course in Health Coaching Step 9: Assess confidence in patient s ability to reach the goal If a patient believes he or she can t do something, they are unlikely to even try even if perceived as important. Conversely, if a patient believes he/she can do something, they will be more likely to try and most likely to succeed. On a scale of 1 to 10, with 1 being not confident at all and 10 being very confident how would you rate your confidence in your ability to (making a particular change or taking a course of action?) Not Confident Very Confident

15 Crash Course in Health Coaching Step 9 continued: Useful strategy to explore/enhance confidence Confidence > 7? It sounds like you might be ready to do something about this. Shall we explore options? Confidence < 7 but > 3? What makes you give yourself a 5 instead of a 2? Encourages patient to reflect upon and talk about efficacy to change and this can bolster confidence. Clinician can reinforce this. Confidence < 2? What would it take (what would have to happen) increase your confidence from a 1 or 2 to a 5? Lets us know what we might offer patient to increase confidence, such as additional information or education about how services or treatments can increase chances of success. Crash Course in Health Coaching Step 9 cont.: Useful coaching actions to enhance confidence Is there anything I can do to help you with that? Teach skills to promote mastery (if low confidence is related to absence of a necessary cognitive or psycho motor skill) Practice actual tasks in small, manageable chunks Modeling have patient observe or talk with others in similar situations who are actively working on the behavior Offer encouragement/support to bolster confidence. Reframe or reinterpret health beliefs or physiologic states Crash Course in Health Coaching Step 10: Develop a follow up plan with the patient When and how will progress toward goal or action plan be reviewed? When helping patient set a health change goal or action plan, it is critical that there is some sort of follow up. Why? Reinforce effort and progress towards health behavior goals Update or change action plans when indicated. 15

16 Using Summaries and Reframing So, it sounds like quitting smoking is very important to you because you want to be around to see your grandchildren grow up. However, you are not confident in your ability to quit, given that you have tried numerous times before without staying quit It sounds like if you had more confidence in your ability to be successful, you might consider making another quit attempt? You were able to quit once for a month. How were you able to do that? What did you learn from that month of success? It sounds like if you had some more information about how other people successfully quit smoking, that might increase your confidence. Understanding Ambivalence Understanding Ambivalence Ambivalence having mixed or conflicted feelings about changing or taking a certain course of action. Manifests in reluctance to take action or make a choice Intensity and breadth of the conflict related to ambivalence may vary. Patient awareness or insight regarding the conflict may or may not exist. Listen for signs of ambivalence. When in doubt, check it out! You seem to have mixed feelings about? 16

17 Ambivalence What Not To Do! Be careful about trying to persuade when encountering ambivalence about making change or taking a certain course of action! It is natural to try to sell the patient on what we think is the best course of action. What s the problem with this? It is that you are helping the patient make the counter argument, the argument for staying the same. Why? The patient may already be vaguely aware of the argument for changing vs. the argument for staying the same (sustaining). Ambivalence What Not To Do! This argument may be raging in their mind already! When you argue for one course of action, you are giving them the chance to make the argument for no action or a different action. In effect, you are getting the patient to make the wrong argument the argument for not changing. By using MI techniques, we help the patient become aware of and explore their own ambivalence. Once Veteran better understands their own ambivalence, our job is to help them make their own argument for healthy change. Exploring Ambivalence Open ended questions are key. Try to avoid questions that can be answered with just a yes or no. Open ended questions invite the patient to reflect upon the pros and cons of various options. What do you see as the advantages of? What would be difficulty about? If you were to make these changes, how do you think your life would be the same or different in one year? We want to ask patient s questions that help them make their own argument for positive change. 17

18 Ambivalence the absence of readiness? Many clinicians start by asking closed questions about readiness to change. This can often be a dead end. Example: Are you ready to quit smoking? What if the patient s answer is No. We are at a dead end. It often is better to start by assessing perceived importance of change and confidence in ability to make change. Why? Assessing importance and confidence correctly provides insight into motivations and potential obstacles, providing an opportunity for health coaching rather than trying to convince. It also helps patient reflect on their own motivations and perceived obstacles to change. Sustain Talk versus Change Talk Sustain talk: patient verbalizations that indicated a lack of readiness to change (or even consider the possibility of changing). Change talk: Patient verbalizations that suggest consideration of change or taking a certain course of action. Change talk can range from tentative contemplation of possible change to firm resolve to change. Through practice, we can develop our ear to detect patient communication that might suggest the possibility of change, and then explore and reinforce that possibility. Change Talk: DARN C Desire: I want to Ability: I can.. ; I could.. Reasons: Doing this will be good for me because.. Need: I must change because Commitment: I will do this.. 18

19 Examples of Change Talk Desire: I would like to lose some weight. I like the idea of having more control over my drinking. Ability: I can stop smoking.i once quit for 3 months. I can take my medications every day if I put my mind to it. Reasons: If I lose some weight, I may be able to take less medication. My wife and kids will be happy if I cut back on my drinking. Need: I got to stop smoking. It s very important for me to work on managing my diabetes. Commitment: I will cut back to no more than 2 beers a day I will check my blood sugars every day Strategies to Explore Change Talk Ask open ended questions as follow up to Change Talk. Why do you want to work on losing weight? (Desire) How might you go about increasing your physical activity? (Ability) What do you see as the benefits of changing your diet? (Reasons) What concerns do you have about potential effects of your high A1c? (Reasons) How important is it for you to lower your sugar levels? (Need) What will you do to help you remember to take your medications? (Commitment) Strategies to Explore Change Talk Importance Ruler On a scale of 1 10 Use your EARS Elaboration and Evoking ask open ended questions about the change talk you heard. Affirmation reinforces the positive ideas about ability to change and benefits of change (catch them being good) Reflections use to reflect back and possibly amplify the change talk. Summaries a type of reflection that brings the information gathered together with an invitation to consider a course of action. 19

20 Develop an Ear for Change Group Exercise: Listening for change talk! I will read a number of patient statements related to lifestyle behaviors. Drum with your hands if you hear change talk (i.e. desire, ability, reasons, need). Stay silent if you hear sustain talk Applaud if you hear commitment talk Dealing with Fear Dealing with Fear When Fear is creating an obstacle to healthy change or course of action: Step 1: validate feelings acknowledge patient s feelings & concerns confirm that it s OK to be concerned use listening skills to elicit what s behind the feeling Step 2: Describe specific, concrete actions to take what the patient can do teach stress management techniques as needed what the treatment team is doing 20

21 Dealing with Fear Step 3: Build confidence tell patient you believe he has or can learn the skills he needs Tell patient you & others will be there every step of the way to help him Don t Arouse Fear in an attempt to leverage change! Research studies show it doesn t work as a behavior change strategy Patient may perceive message as a threat People often react to threats by becoming anxious People try to avoid things that make them anxious Dealing with Fear Don t arouse fear So arousing fear can make resistance and avoidance worse Don t over emphasize what will happen to patient if he doesn t follow your advice People with low self esteem & those who think they re vulnerable to negative consequences are easily frightened If they perceive that a negative consequence is inevitable, they may not even try to change If they have failed in the past, they may be afraid to fail again 21

22 Dealing with Fear If a patient avoids any discussion of his problems or regimen, it may be because he is already frightened Using fear arousal to break down avoidance will likely make the situation worse Never say Don t worry to a patient Helping patients deal with fear Step 1 validate feelings Step 2 describe specific actions to take Step 3 build confidence Dealing with Resistance Dealing with Resistance There are numerous reasons that resistance may manifest itself in a clinical encounter. In addition to ambivalence and fear (already discussed) reasons could include: A high need for control and/or power Baggage from past clinical interactions Transference/countertransference Oppositional personality traits Low need or perceived importance for engagement in health care 22

23 Dealing with Resistance Resistance can also be manifested in different ways Quiet reluctance in the patient Denying blaming, disagreeing, excusing, minimizing, pessimism Arguing challenging, discounting, hostility Interrupting Ignoring inattention, non answer, sidetracking Causes of Resistance Patient brings conflicts into the encounter Clinician elicits resistance from the patient Combination of the two Some patients will be particularly sensitive to the way they are spoken to Resistance occurs in the interpersonal context between clinician and patient What not to do! Avoid statements or actions that would appear to take control away from the patient Make assumptions about or misjudge importance, confidence, readiness Make assumptions about what is causing the resistance. Make attributions to character or personality Become judgmental or critical Meet force with force 23

24 What to do! What TO do when encountering resistance in a clinical interaction? Recognize or become aware that resistance is occuring. Back off and come alongside the patient Emphasize personal choice & control Re assess readiness, importance, confidence Health Belief Assessment The Health Belief Assessment can be a very useful tool for helping us understand what is behind or causing resistance or conflict. Each person has 5 9 ideas or opinions about a given topic Let s try it! When you think of Thanksgiving, what comes to mind? Health Belief Assessment in Action As applied to medical situations? Suppose you are recommending a diagnostic procedure or a certain medication, but the patient appears reluctant (but does not offer the reasons for their reluctance). When you think of taking medication for your blood pressure, what comes to mind? When you think about colonoscopy, what comes to mind? When you think about idea of quitting tobacco, what comes to mind? 24

25 Honor the patient. It is important that we are aware of our own values and biases when it comes to healthcare decisions and lifestyle. Why? When we encounter resistance or conflict in a clinicianpatient relationship it is often related to a discrepancy between our values/biases/beliefs and those of our patient. Ultimately, we have to accept that the patient is the expert in their own life Honor the patient. Even if we think the patient s choices are wrong, it is still their choice. We don t have to agree with the patient s values and choices, but we have to honor that they are the patient s values and choices based on the patient s own assessment of their own life circumstances and priorities. Avoid Judgment: Patients can sense when we are being judgmental about their choices. The danger is that rapport is destroyed and we lose our potential to promote positive change in the future. Questions and Comments 25

26 Motivational Interviewing Resources Motivational Interviewing: Helping People Change; 3 rd Edition. Miller, W. & Rollnick, S., The Guilford Press, Motivational Interviewing in Health Care: Helping Patients Change Behavior. Rollnick, S., Miller, W. & Butler, C., The Guilford Press. Building Motivational Interviewing Skills: A Practitioners Workbook. Rosengren, D. The Guilford Press,