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Transcript of Facilitating Change
Facilitating Change Motivational Interviewing
Setting Goals for Change
Ideally, the goal must be the patients goal, unless the goals are in the Best Interest of the patient.Break the goal down into manageable chunks. If the person feels they have failed to achieve a goal, review it, modify the goal (simplify it, put supportive strategies in place) and try again.
Facilitating Behaviour Change & Motivational InterviewingCycle of Change (Prochaske & DiClemente, 1982)
Individuals have very basic motivations, and more complex ones.Motivation is not a personality trait or a static, stable entity (as in she is a very motivated person) but rather acknowledges that we all have motivation
Stages of ChangePre Contemplation - The person is not feeling ready to change, or even really thinking about it. Contemplation - The person may start to become more and more aware of the potential benefits of making a change.Preparation - At this point, the person has decided that they definitely do want to make a change, and start to make plans for how they can overcome barriers to change. Action - The person is making active attempts to change. Maintenance - The person may gain confidence as they see themselves making progress and become assured that they will be able to change. Relapse - The person loses all intention to carry on with the changes they are trying to make.
Motivational InterviewingOnce the importance of change has been explored, and if it is felt that changing is important, then confidence can be brought into the equation.
There needs to be a high level of both importance and confidence for change to occur.On a scale of 1-10, how important is it for you to change right now?1 2 3 4 5 6 7 8 9 10
On a scale of 1-10, how confident do you feel that you could change?1 2 3 4 5 6 7 8 9 10
Resistance to ChangeIf you feel that a person is being resistant to change, you need to change your tack.
How resistance is communicated:Body language e.g. avoiding eye contact, folded arms.Presenting reasons for not changing (e.g. Yes, but)Making excuses for not changing.Disputing or directly challenging you, your information, and your competence.Arguing, interrupting, ignoring or denying
Overcoming Roadblocks and Resistance
StageTechnique/StrategyPre-Contemplation Roll with ResistanceDevelop DiscrepancyContemplationAffirming Provide personally relevant informationScaling questionsPros and cons listRoll with resistanceExplore barriersDecisional balance sheet Determination/PreparationAffirming Action plan motivation list, problem solving, final barriers ActionPraise, support, reinforcementAmendments to action plan Maintenance Reinforcement and rewardsPre-empt slips /relapse preventionPraise emphasis on gains
Overcoming Roadblocks and ResistanceRoll with Resistance - Avoid confrontation and try to get the person you are working with to recognise that they need/want to change themselves (rather than being told).
Rolling with Resistance Approaches:
Avoid Arguing - avoid having a direct, head-on argument with an individual as this is likely to make them feel defensive. Listen - By showing that you have heard what they are saying, you may prevent them from instinctually being defensive Encourage - encourage the individual to come up with their own suggestions for ways of changing their behaviour Reflect - By doing it in a non-judgmental way, they will be assured that you are simply trying to understand them, rather than contradict them or express your own views. Alternative viewpoints - By doing this, you are getting them to look at the other side of the argument but without directly challenging their views or passing judgment on their choices.
Overcoming Roadblocks and ResistanceDevelop Discrepancy - The aim of this strategy is to show a person that there is a discrepancy between their current behaviour and their desired or ideal behaviour. Affirmation - Affirmations are statements that acknowledge and recognise the positive steps that a patient has made in the direction of change. Provide Personally Relevant Information - The things that make people really want to change are the things that are personally relevant to them.
Overcoming Roadblocks and ResistanceScaling Questions - Scaling questions can be really helpful as they often allow you to break up the whole process of change into smaller chunks, making it less daunting for patients. Pros and Cons List - It can be hard to see the big picture but when its all written down in front of you, you can really begin to see how many benefits there could be to changing.Explore Barriers - It is also important that you explore the barriers that are preventing change or making change more difficult., and validate these so that the person knows that you are acknowledging how difficult it is for them to be changing their behaviour.
ActivityOne way of exploring pros and cons, is to use a decisional balance worksheet with patients.This allows you to not only look at the pros and cons of changing, but also the pros and cons of not changing (in reality, there are positives to carrying out behaviours which are bad for us otherwise we wouldnt do them! It is important to acknowledge this as well as looking at the negatives of a given behaviour).Draw out your own decisional balance sheet, and either use a change which you would like to make, or make up an example (e.g. stop smoking, eat healthier diet, cut down alcohol).
Pros Cons Change No Change
Overcoming Roadblocks and ResistanceAction Plan - An action plan is a formal, written up plan of steps to take towards change. After setting a goal, ask the patient, how confident do you feel that you can achieve this goal on a scale of one to ten. If they give a number of 6 or lower, you might want to explore the reasoning behind this, and if needs be, change the goal until it becomes something which they actually feel confident that they can achieve. Praise Support and Reinforcement - It is important that all steps towards changing are acknowledged and praised, no matter how small they are. There is never a black and white divide of succeed and fail, think of these two points as being either side on a gradual scale: Fail Made some progress Made moderate progress Made good progress Succeed
Overcoming Roadblocks and ResistanceAmendments - Changing a goal to make it more achievable is not a failure; it may just be that the original goal was not realistic enough or not attainable at the current point in time. It is much better in the long run to amend goals and action plans than it is to stay focused on an unachievable goal. Rewards - When people are trying to change, it can be nice to know that at the end of each step there is a reward waiting for us. It doesnt have to be something big or expensive, just something which feels rewarding for that particular individual. Pre-empt Slips/Relapse Prevention - The key to making successful changes is to be aware of situations which might lead to us slipping up, be prepared for the possibility that we might slip up, and plan for what we will do afterwards.
SummaryThere are many reasons why an individual would want to change, or would not want to change.Our behaviour and motivations are all extremely personal, so telling someone what they should do and why they should do it, very rarely works. Assess and facilitate motivation for change through motivational interviewing. Find out your patients motivation and let them do the reasoning (with a little guidance from yourself).Use the tactics outlined to overcome roadblocks to change and remember that most people will have slip ups/relapses it is all part of changing.
Goal setting is an important part of change as it allows people to set out exactly what they are aiming for. Different people will have different priorities in terms of what is important to them some may set goals towards changing their lifestyle after stroke, others may wish to focus on returning to work, or resuming social activities.
When setting goals with a patient, try to ensure that they are able to decide their own goal and that they are happy with the way it is broken down into smaller steps towards success.
If a goal is not achieved, talk this through with your patient and try to identify the reasons for the goal not being met. Modify the goal with these in mind, perhaps simplifying it or putting supportive strategies in place to help.*In 1982, Prochaske and DiClemente came up with a model that describes the cycle of change, describing change as a process rather than an event. They felt that motivation to change was very complex, with individuals describing very varied reasons for wanting to change. Research has shown that this model can be applied to many types of human behaviour, for example addictions and lifestyle changes such as eating healthily or doing exercise.
It can be helpful to think of this cycle of change when working with patients, as you be be able to identify what stage your patient is currently at. This will help you to help your patient to change as the type of intervention that might be used in one stage, will not necessarily be beneficial in a different stage.
*It is important to note that people will not necessarily follow this cycle in perfect order, they may go back and forth between stages for a while, or they may slip up for example at the maintenance stage, and then go right back to contemplation. This is completely normal and most patients