1. Eliciting Individual Change

3.  Motivation is a key factor in behavior change and has been
shown to promote adherence to long-term therapies.
 Motivational Interviewing is a tool utilized to determine
readiness to change and assist in facilitating motivation
and action.

4.  Behavior change often occurs gradually over time. By
assessing where a person is in the process of changing,
interventions can be tailored towards that stage of change.
 There are 5 stages of change:
1. Pre-contemplation
2. Contemplation
3. Preparation
4. Action
5. Maintenance

5.  Readiness to Change Ruler:
◦ Emphasize you are collaborating: “why do you think you’re here?”
“would you mind if we talk about your drinking?” etc
◦ A useful tool to gauge person’s self-reported motivation to change.
◦ Ask:
 “On a scale of 1 to 10, how ready are you to change?”
◦ Whatever the response follow up with:
 “What do you think it will take for you to move to a_____?”

6.  The person is not even considering changing. They may be "in
denial“(or unaware) about their health problem, or not consider it
serious. Conversely, they may have tried unsuccessfully to change
so many times that they have given up.
 What can be done?
◦ Educate on risks versus benefits and positive outcomes related to change.
 Provide person with some element of control.
 Emphasize internal locus of control- THEY can do it, you’re just helping facilitate it.
 Consequence-based Arguments on need for change
 What is the best outcome if you don’t change? And if you do?
*The goal of this stage is not to elicit change but to elicit thoughts of change…
Get them thinking about the importance of change!

7. Three factors need to be addressed:
1. Desirability
2. Likelihood
3. Counter-arguments

8. 1) Desirability
 Messages pointing to highly desired consequences.
◦ ***Need to adapt message to what target audience desires.
(different people value different things).
 For some, negative social consequences may be more
important than long-term consequences.
◦ I.e. Looking cool is more important than worrying about your liver
when offered drinks etc…

9. 2) Likelihood
 Need to convince audience the likelihood of the desired
outcome.
◦ Compare to others(before and after in small cases or statistics in large
studies). E.g. on average 76% people lose __-weight or “look I lost 75
lbs on the ___ diet”
 Describe underlying mechanism- explain the process of how
the action can lead to desired outcome
 Best is to incorporate comparisons and explanations

10. 3) Counter-Arguments
 Even if beliefs about desired consequence is accurate(e.g.
healthy diets lead to decreased diabetes), behaviors may reflect
inaccurate beliefs(healthy diets are boring, flavorless etc)
◦ Need to refute if possible.
 If you cannot refute(because they have merit) try to overwhelm
counter-arguments with many points and not mention counter
argument.
 In a situation when there isn’t trust(like politics or in some
health care settings), addressing counter-arguments can help
gain trust.
◦ “Look, there is no perfect solution and while____ has some merit, it would
be more beneficial for you to____”

11.  The person is ambivalent about changing. During this stage,
the person weighs benefits versus costs or barriers (e.g., time,
expense, bother, fear).
 This is where motivational interviewing can really help!
 Work to:
◦ Address concerns
◦ Identify support systems
◦ Identify barriers and misconceptions

12. Social Factors Influencing Action
 Even if person knows of the consequences and believes that
the action needs to take place, there are two factors that still
might prevent them from acting:
◦ Descriptive and Prescriptive Norms

13.  Descriptive norms are a person’s perception on whether
others perform given behavior.
◦ More likely to do something if they think that others are also doing it.
 Combat that by issuing descriptive norms that support your
recommendations
◦ Try to find confirming actions of peers and social network to increase
their likelihood of doing it.
◦ E.g. Join a FB page about exercise and Pinterest about healthy diets
and as you surround yourself with these people’s behaviors, you,
yourself, are more likely to do them.

14. Prescriptive norms are people’s perceptions of what other people think
that they should do. So even when their own attitudes are positive, they
don’t do something because of what they think others want them to do.
 If they think other people are opposed to the action, then they may
be less apt to do it.
◦ Strategies to combat negative prescriptive norms:
 De-emphasize prescriptive norms. Should encourage more weight
on own attitudes(if they are motivated)
 Try to discount negative people’s ideas
 Change prescriptive norms: Need to communicate with the third
party(e.g. spouse/family members) in order to change their
attitudes in order to elicit the desired action.
 e.g. talking to parents of army recruits…

15.  The person is prepared to experiment with
small changes.
 Help to:
◦ Develop realistic goals and timeline for change
 Limit choices as not to develop decision paralysis which
can lead to dissatisfaction and decreased confidence.
◦ Provide positive reinforcement

16. Perceived Abilities
 Even with positive attitudes and addressing both prescriptive
and descriptive norms, if low perceived ability: less likely to
do action.
◦ e.g: understanding the need for exercise, having friends that do it, and
know others want them to exercise, may still not exercise because they
lack the perceived ability.
 In these instances, educating them on the need isn’t the
problem, it’s educating them how to do it.

17.  3 Strategies to Influence Perceived Ability
1. Remove Obstacles
2. Rehearsal
3. Modeling

18. 1) Remove Obstacles
 Sometimes the obstacle is simply a knowledge gap and
providing patients with appropriate knowledge on how to do
something can solve it.
◦ E.g. someone who knows they have to exercise but don’t know how to
exercise
 Sometimes it’s a materials obstacle
◦ If, for example, transportation is limiting their participation in desired
action, can we find another way to do it that results in the same
outcome?
◦ Telling someone to do something without taking into consideration
their material obstacles is likely to be less effective.

19. 2)Rehearsal
 Provide Opportunities for patients to learn in a controlled
environment.
◦ e.g. exercising in sedentary older adults: give at least one supervised
training session increases their perceived abilities.
◦ e.g. role play conversations about good relationships(safe sex etc)
 **Once they see themselves do it, they know that they can!

20. 3) Modeling
 Seeing someone else successfully performing the behavior.
◦ e.g. Teachers watching other teachers implement certain teaching
techniques
**vicarious success still will help convince them that they can
do it(if they can do it, I can do it).

21.  The person takes definitive action to change behavior.
 At this point we are providing positive reinforcement
 Also can utilize strategies to ensure intention turns to
action:
1. Prompts
2. Explicit Planning
3. Inducing Guilt

22. 1)Prompts
 Reminder/trigger/cue to draw attention to performing
action(cues that make behavioral performance salient)
◦ e.g. Sign(of benefits of exercise) by stairs will increase use of stairs
◦ e.g. hand washing signs in public restroom
*prompts won’t always work. Need to have:
◦ Willingness to do behavior
◦ Perceived behavioral ability sufficiently high so that think they can do
the behavior

23. 2) Explicit Planning
 Get patients to write down the specifics of the
when/where/how…
◦ e.g. study participants who specify when/where/how they will exercise,
are more likely to do it.
***Encourages a transition from abstract intention to more
specific concrete intention(and thus action)

24.  3) Eliciting Guilt
 Making people uncomfortable with their inconsistencies
 Need existing positive attitudes and intentions occurring with
inconsistent with the behaviors. Thus can induce guilt.
◦ e.g. Provide not only feedback on their actions(e.g. they’re not doing it) AND
reminder of their positive attitude when they said they would do it.
*Can be negative if:
◦ Scolding is overt(instead just lay the ground work so they draw their own
conclusions)
◦ Perceived behavioral capabilities aren’t high->if you draw attention to their
inconsistency it may confirm that they are not able to do it.
*people NEED to think they can do the action.

25.  The person strives to maintain the new behavior over the long
term.
 Primarily just here to provide encouragement and support
◦ Can utilize same three techniques in Action phase to
ensure that they maintain behavior

26.  40 year old male comes into your health clinic accompanied
by police. The night before he had gotten into a fight while
drunk and broke his nose.
 Discussing his situation with him, he states that he didn’t
think it was an issue and that it was the other person’s fault
for spilling his beer on him and that he had no problems.
 Even when reviewing that this was his third time in as many
weeks that he had had to come to the health clinic, he denied
that alcohol may be a contributing factor.

27.  What stage is he likely in?
 What can/should we do at this stage?
 How would this change if he admitted he had a problem but
didn’t feel that he had the power to make change?

28.  Perceived Self-Efficacy/Skills
◦ An individual's belief that he or she can do a particular behavior given
their current knowledge and skills; the set of knowledge, skills, or abilities
necessary to perform a particular behavior.
 Perceived Social Implications
◦ Perception that people important to an individual think that s/he should
do the behavior; norms have two parts: who matters most to the person
on a particular issue, and what s/he perceives those people think s/he
should do.
 Perceived Positive Consequences
◦ What positive things a person thinks will happen as a result of performing
a behavior.
 Perceived Negative Consequences
◦ What negative things a person thinks will happen as a result of performing
a behavior.

29.  Self-efficacy reflects confidence in the ability to exert control
over one's own motivation, behavior, and social environment.
 Self-esteem reflects a person's overall subjective emotional
evaluation of his or her own worth.
 Locus of control reflects a person’s belief of how much
control they have on events affecting them.

30.  OARS
◦ Open Ended Questions
◦ Affirmations
◦ Reflective Listening
◦ Summarize

31.  Try to avoid questions that can be answered with yes/no
responses.
 Open with something like: “why are you here today?”
◦ By offering open-ended questions, you allow the person to express their
thoughts and motivation(or resistance) to change.
 Other examples of open-ended questions:
◦ How can I help you with ___?
◦ Tell me more about_____(I do realize that’s not technically a question.)
◦ How would you like things to be different?
◦ What are the good things about ___. What’s no so good about it?
◦ When would you be most likely to___?
◦ What do you think you will lose if you give up ___?
◦ What have you tried before to make a change?
◦ What do you want to do next?

32.  Affirmations are used to recognize client strengths and
acknowledge behaviors that lead in the direction of positive
change. They build confidence in one’s ability to change. To
be effective, affirmations must be genuine and consistent.
 Examples of affirming responses:
◦ I know you didn’t want to come today but I appreciate that you did.
◦ You handled yourself really well in that situation.
◦ That’s a good suggestion.
◦ That is a tough situation and you seem to have managed it well.
◦ I’ve enjoyed talking with you today.

33.  This is the crux of MI. It is the pathway for engaging others in
relationships, building trust, and fostering motivation to
change.
 Reflective listening is meant to close the loop in
communication to ensure breakdowns don’t occur.
 There are three times of reflective listening:
◦ Repeating or rephrasing: Listener repeats or substitutes synonyms or
phrases, and stays fairly literal in person’s meaning.
◦ Paraphrasing: Listener makes a restatement in which the speaker’s
meaning is inferred.
◦ Reflection of feeling: Listener emphasizes emotional aspects of
communication through feeling statements.

34.  Summaries build upon reflective listening. The idea is that you
person the person’s argument back to them to elicit change
thoughts.
◦ Start with a transition statement like: “Let me understand so far…”
◦ Point out any change statements that were made(like “I know my
drinking is an issue”, “Something needs to happen, I just don’t know
where to start”)
◦ If ambivalence is expressed, pose it like “on the one hand you… but on
the other…”
◦ Summarize with a statement like: “Have I missed anything?”

35.  The obvious hope is that when you finish your summarizing
statement, you move immediately move towards an action plan.
 REMEMBER: it is all about their stage of readiness to change.
◦ This conversation may have moved them from the pre-
contemplation to contemplation stage. That is still progress!
◦ Empowering the person and working on developing an
internal locus of control, high self-esteem and efficacy is an
important step towards eliciting change.
 Avoid Learned Helplessness! Empower people to make
changes.

36.  Break out into pairs of two. One person role-play as a
“difficult” patient in 1)pre-contemplation, 2)Contemplation or
3) Preparation stages. The other practice OARS and assess
how different strategies and tools will be needed for each of
these “patients”.
 Switch roles

37.  Getting people to change is not as simple as telling them what
is best for them.
◦ There are many factors that can contribute to whether they will.
Attempt to consider them all with your interactions and you will likely
increase their success.