Practical Hints and Tips for Assessing

Readiness to Change

Dr Bronwen BonfieldPrincipal Clinical PsychologistCommunity Neurological Rehabilitation ServiceBuckinghamshire Healthcare TrustNovember 2016

Aims of the SessionTo have increased awareness of

the factors that affect an individuals readiness to change.

To explore the theoretical models that underpin change behaviour

To develop awareness of skills and strategies to support individuals and their families.

CNRS In-Service Background to experience in this area: Multidisciplinary team inservice topic over

the last year. Explored the main question regarding

‘Why don’t some people progress as we would expect (achieve functional change and learn to self-manage their condition), when they present with sufficient levels of physical and cognitive skills to do so?’

Led the team to develop three clinical questions What affects a persons motivation and readiness to change? What skills as clinicians do we need to identify and draw out a

client’s readiness to change within neurological rehabilitation? How can we provide the right therapy, to the right patients at

the right time?

Rehabilitation in MSMuch of neurological rehabilitation is interested

in helping people to manage functional change over the duration of their condition (Therapists in MS delivering the long term solutions 2006).

A growing body of evidence emphasises the importance of effective self management of long-term conditions. It is recognised that those people who successfully self-manage their condition experience better health outcome (Hibbard J & Gilburt 2014)

Self-Management - The importance of well-being

Living a meaningful life that is striving towards what we value promotes well-being.

Each individual will have their own set of values which creates meaning.

When our lives are “in balance” we have capacity to deal with life’s events – whether positive or challenging.

We can enjoy the positives and manage the challenges.

Our lives are like jigsaws – when they fit together to make a whole – again life seems manageable.

However, when we experience stressful life events, changes to our health – our life jigsaw is thrown up in the air, breaks up and lands disjointed.

It takes time, support and advice to get the jigsaw back together and sometimes it does not fit quite as it did before.

Adjusting to this and accepting this new position, physically, emotionally, will enable us to regain balance in our lives.

The Biopsychosocial Model

Biological/Physical Impact

Social ImpactPsychological

Impact

We need to understand the factors that interact and inform our well-being

Challenges in Rehabilitation

‘Why don’t some people progress as we would expect (achieve functional change and learn to self-manage their

condition), when they present with sufficient levels of physical and cognitive skills to do so?’

How our clients presentWhen I get better…….

When I get back to normal

Work within the session –

no carry over

Family report

frustration – no action

Yes….but

Family want more

rehabilitation

The Therapist ResponseThey have potential – I must fix this

Why aren’t they moving forward?

What can I do next?

Frustration

Heartsink

Doubt

Uncertainty

Burn out

Effects of the cycle

Patients remain in therapy for longer periods of time Expressed higher levels of dissatisfaction when

discharged Re-referred quickly either by external referral or self-

referral Therapist dissatisfaction Challenges within the therapeutic relationship

How do we understand this behaviour?

There are multiple models that can inform us: social cognition model, health belief model and stages of change model

We will focus on stages of change model

Precontemplation

Contemplation

ActionMaintenance

RelapseIndividual

leaves Treatment

Stages of Change Model

Precontemplation

Client not intending to change or not aware of the need to do so…

We identify these clients as RED Flag

Contemplation

The individual has some awareness that they have a problem and they are thinking about changing.

We identify these clients as YELLOW flag

Action Actively taking part in behavioural change (e.g. active participant in rehab programme)

We identify these clients as GREEN Flag

In our service we have identified that 60% were green and 40% amber/red

Maintenance & RelapseMaintenance

Making good progress (e.g. taking responsibility for self-management of condition)- this would represent clients who have achieved goals – we may review and then discharge

RelapseClient reverts back to earlier stage of cycle of change

Factors that are barriers to change Lack of awareness of rehabilitation process. Lack of self awareness. Poor insight. Cognitive/emotional deficits. Denial Negative perception of self. Unhelpful belief system/rules for living. Lack of MDT approach. Poor acceptance. Inability to reform values. Inability to remodel self. Feeling powerless. Over protection by others.

Hints & Tips Within any therapeutic relationships key skills are:- Remembering it is a partnership; working in

collaboration- Empathy and compassion - Acknowledging the individuals strengths and

efforts- Open questions- Reflective listening - These are core skills in Motivational

Interviewing - strengthening an individual’s motivation and commitment to change.

Hints and Tips cont… Precontemplation from a service perspective these are clients who need preparation before entering a rehabilitation programme.

- Psychological Group programmes re: acceptance to their condition

Other strategies if this is not available:- Listen and summarise the clients issues- Raise awareness of the benefits of the service available to them- Raise awareness of the disadvantages of staying as they are- Preserve the therapeutic relationship to enable access to the

service at a later date.- Information – leaflet with contact details on. Check the meaning

of the information to the client.

Hints and tips cont…Contemplation Support the client’s problem-solving and

decision making by: - discussing advantages and disadvantages of changing in relation to client (rather than in general)

help client identify where they would like to focus attention first

acknowledge that behaviour change is not easy – provide opportunities for person to voice their reservations about taking action

offer further support e.g. via follow-up appointment

Hints and Tips cont….Agenda Setting

◦Can be a very useful way of identifying current priorities

Hints and Tips cont… Confidence Scales

Using a confidence scale can indicate how the client actually feels about completing a task

For the task to be realistic the rating should be around 6 – 7

0 1 2 3 4 5 6 7 8 9 10

If the client rates the task 8 – 9 – it could reflect something they are already achieving or something that will not move them forward.

If the client rates the task 5 and below it enables further exploration

Hints and tips cont…Action Helping client identify strategies that

work for him/her Acknowledge success to bolster

confidence and self-esteemProvide strategies to help reduce stress

(e.g. relaxation techniques) Set further achievable goals; consider

client keeping diary to monitor behaviour so clinician can help identify what may be preventing progress

Hints and tips cont….Relapse Reinforce to client that this is a

normal experience and does not signify failure Discuss triggers; identify

strategies that have worked so far Help identify where client needs

to jump back onto the ‘wheel’

Hints and tips cont….MaintenanceReinforcing the strategies that

have helped the clientStart bringing in other sources of

community support Agreeing follow-up appointment

or phone call; assurance that support is available if the client needs it

Factors that promote behavioural change Goals Action Phase Use of Motivational Interviewing. Feeling empowered. Peer support. +ve patient/therapist relationship Management of expectations. +ve feedback on performance. +ve outcome facilitating on-going change. Follow-up. Acceptance and re-formulation of values. Ability to remodel self.

Team Considerations Current knowledge

Skills and effectiveness in change behaviours

Evaluate current practices

Identify training needs

Referring OnIf the barrier to change is linked with depression or anxiety then referring to a psychological service will be helpful.

Thank you for listening

Any Questions?

Social Cognition Model

“The beliefs that individuals hold about the outcomes of their actions are key determinants of their health-impairing or health-protective behaviours”

Cognitive representations of health threatEmotional response to health threat

Health Belief Model “The Health Belief Model

assumes that for a person to engage in a recommended health-protective behaviour, they must perceive the benefits to outweigh the costs”