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Negotiating behaviour change – the problem

Negotiating behaviour change – the problem. ‘…….clinicians with a low sense of self-efficacy making repeated exhortations to disinterested patients to change’ Rollnick et al 1997. Motivational Interviewing. 1990’s – brief intervention therapy 5-15% success rate for GP’s

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Negotiating behaviour change – the problem

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  1. Negotiating behaviour change – the problem ‘…….clinicians with a low sense of self-efficacy making repeated exhortations to disinterested patients to change’ Rollnick et al 1997

  2. Motivational Interviewing • 1990’s – brief intervention therapy • 5-15% success rate for GP’s • Public health view vs. • 9/10 failure rate – demoralising and seems sometimes to damage rapport with patients

  3. Motivational Interviewing ‘Changing for Good’ 1994 Prochaska,Norcross & DiClemente

  4. Motivational Interviewing Roll with resistance Exchange Information Will involve a conscious change from ‘treating’ to discussing how people will change their own lives – even more patient-centred

  5. Motivational Interviewing • Person centred • What do they really want • Respectful • Autonomy – right to choose • Enabling • Helping others to feel in charge of themselves and their own future – they make the decisions

  6. Motivational Interviewing • Weighing up pro’s and con’s to evaluate FOR THEMSELVES the importance of change • Rolling with resistance to avoid argument, entrenchment, denial Traditional motivational interviewing takes 45 mins. but can be condensed into 9 with practice or even smaller segments (Motivational Interviewing: Miller and Rollnick 2002)

  7. Doctor Structure/ direction/ support Information Elicit views and aspirations Negotiate sensitively Patient The decision maker Takes the action Motivational Interviewing

  8. Motivational Interviewing • Make it clear it is your job (Makes it easier and guards against ‘nosiness’) • Show them you won’t judge (Start with an affirming statement) • Remember not to jump ahead (Making a change is a journey and people must make it for themselves)

  9. Motivational Interviewing Substance misuse • Agenda setting idea: • Most manageable vs. impossible (latter usually seen as the most important!) Alcohol Food intake Medications Exercise

  10. Motivational Interviewing • Importance: The expectation of costs and benefits • Confidence: The anticipated ability to achieve change if an attempt is made Smokers 1 ✔ 2 ✘ Drinkers 1 ✘ 2 ✔

  11. Motivational Interviewing • Some techniques:- • Scaling questions • on a scale of 1-10 how important is it to you… • how confident do you feel that you might change if you chose to… • Why is it as high as that? • What would it take to move you one step higher? • What number would it need to be on to give it a go?

  12. Motivational Interviewing 2. Importance If this is low in score try looking at it this way: What are the good things about……? What are some of the less good things about…? Is there anything else? Where does that leave you now?

  13. Motivational Interviewing 3. Confidence • Brainstorm solutions (try to come up with a >10 between you, use a full range of ideas!) • What have you learned from previous attempts – what works for you, or doesn’t work? (they may have tried umpteen times in the same way or experts by experience!) • Is there anything you know of that has worked for other people? (often more compelling than the evidence!) • Aim for a clear plan that can be reviewed at any time (Manageable steps – AA ‘1 day at a time’)

  14. Motivational Interviewing 4. Information giving is sometimes needed :But much less often than we think: • Establish what is already known and interest in receiving information (‘There’s a lot more I could tell you if you’re interested…..’) • Provide information neutrally and if possible visually (‘…what usually works for people…) • Helpful to give information sheet to take away (most decisions made by people when they quietly reflect) • Elicit the interpretation of this and follow it up (‘..has this made any difference to the pro’s and con’s?..’) ‘Motivational interviewing is close to the polar opposite of advice-giving’ Rollnick, Heather &Bell 1992)

  15. Motivational Interviewing • Responding to change talk • Reflect (paraphrase) • Ask for elaboration – especially examples • Ask ‘What else?’ • Affirm and encourage • Summarise – where does this leave you now? (Back to scaling Q’s?) • Always try to get into a position where the patient hears him/herself talk positively about change

  16. Motivational Interviewing • ‘Rolling with resistance’ Watch for more subtle resistance body language, multiple reasons for inability to change, 'yes but’, passivity, appearing to comply but no action etc. • Emphasise personal control • Resistance can be a sign to change strategies • Arguments must be avoided • Confrontation is a goal not the style • May end with respecting their decision not to change • ‘What would need to happen to make you change your mind? • Psychology of opposites • Explain own concerns and ‘leave the door open’ for future discussion

  17. Motivational Interviewing • Empathise • Assist • Encourage Get the patient to hear themselves talk positively about change

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