1. Facilitating Behavior Change:The Transtheoretical Model of Behavior Change andMotivational Interviewing Barbara Chase, MSN, ANP-C, CDE Sandra O’Keefe, CWC

3. Define the 5 stages of the Transtheoretical Model (TTM) for behavior change

4. Assess patients’ current stage of behavior change using TTM

5. Identify the 10 processes of how to progress through TTM stages

6. Define Motivational Interviewing (MI)

7. Describe skills, styles and strategies used in MI

9. Criteria for successful completion include attendance at the entire event and submission of a complete evaluation form.

10. Barbara Chase, MSN, NP, CDE has no conflicts of interest to disclose.

12. Philosophy of Empowerment (The patient is always the expert on himself) Patient defines problem Patient identifies feelings Patient develops long term goals Patient identifies short-term plan Patient implements & evaluates plan 5

13. How do our perceptions change?

14. Change Process May Not Be Linear!

16. 5 Cognitive:

17. Get information

18. Being moved emotionally

19. Considering how the behavior affects others

20. Self-image

21. Social Norms

22. 5 Behavioral:

23. Make a commitment

24. Use cues

25. Use substitution

26. Social Support

27. RewardsProchaska, J.O., & DiClemente, C.C. 1983

29. Motivational Interviewing A directive, person-centered counseling style for increasing intrinsic motivation by helping clients explore and resolve ambivalence (Miller & Rollnick, 2002) 10

30. Motivational Interviewing MI is a collaborative approach to helping people change their behavior regarding their health Patient centered skills, styles, strategies can be learned by many members of the care team Promotes change from within not from without 11

31. Motivational Interviewing Identifies, explores, resolves ambivalence Reveals patient motivation Enhances conviction Stimulates readiness for change Creates a partnership not expert/recipient roles 12

33. Expressing Empathy Actively listen Create safe accepting environment Encourage expression of personal thoughts, feelings, and experiences Identify ambivalence 14

34. Expressing Empathy Provide support and relay facts Avoid giving advice or direct teaching unless requested Patient determines pace and direction of conversation Patient makes the decision to embark on behavior change 15

35. Developing Discrepancies Identify the core values of the patient Determine if the patient’s current behavior is c/w or in conflict with those values Uncover/expose discrepancies between patient’s current behavior/values and future aspirations 16

36. Developing Discrepancies Assist patient to explore the negative outcomes of current behavior Encourage discontent/discomfort that will foster change Patient responsible for integrating facts, resolving discrepancies, building motivation to take action 17

37. Rolling with Resistance Work in tandem with patient exhibiting reluctance to take action Do not coerce or lead but facilitate greater motivation Foster new ways of thinking about the situation 18

38. Rolling with Resistance Avoid making recommendations or expressing bias Patient in charge of generating solutions that are feasible, workable, given personal priorities, goals and circumstances 19

39. Rolling with Resistance

40. Supporting Self-Efficacy Reinforce patient’s confidence in taking action and making behavior changes Promote an atmosphere of optimism Support belief that patient can perform specific tasks they set out to accomplish 21

42. Best past experiences

43. Vicarious experiences

44. Mastery Experiences:

45. Success breeds success!

46. Set SMART Goals-

47. S-Specific

48. M-Measurable

49. Action-based

50. Reasonable

51. Time-lined

55. Intention to change 24

57. Ability: I could, I might, I can

58. Reasons: I know if I walked after work I would lose weight

59. Need: I need to, I should, I must

60. Commitment: I’m going to, I intend to

61. Taking Steps: I started checking my blood BG levels as you suggested 25

63. Discloses your patients’ feelings, fears, and beliefs about their diabetes

64. Can provide context for your patient’s action or lack of action

65. Helps you to connect with and better understand your patient 26

66. Reflective Listening Reflects acknowledgment of patient intent Patient: “I’ve really had a hard time with convincing my family that I need to have different food. They continue to buy cookies and deep fry stuff so it feels like they really don’t care. I’m so frustrated and angry about this I can’t stand it.” 27

67. Which Response Reflects Reflective Listening? Diabetes Educator 1: “It sounds like you haven’t been eating the way we discussed that you should.” Diabetes Educator 2: “You are really upset with not getting the support you would like from your family.” Diabetes Educator 3: “I’d really be mad about this, too.” 28

68. Expressing Empathy Shows that you appreciate their perspective Patient: “Living with diabetes stinks! I can’t eat what I want, I have to take these shots, and I have to have all those pokes, and my friends treat me like I’ve got AIDS. My parents are always on my back and I just don’t feel like doing it anymore.” 29

69. Which Response Reflects Expressing Empathy? Diabetes Educator 1: “I’m sorry, but you have to keep taking these shots. You know you’ll become sicker if you don’t. Diabetes Educator 2: “You know you can really eat most anything within reason. And I’m sure your parents are just scared. They’ll let up in time.” Diabetes Educator 3: “I think if I had something that changed my life so much, I’d be pretty angry too” 30

70. Words of Affirmation Recognizes strengths and accomplishments Thank you for … I really like the way you … That was a very creative way for you to … You showed a lot of self-control in the way you … It may not seem like much, but I think it was very impressive how you … You have a real gift for … 31

71. Importance of Summarizing Helps patients hear and understand what they are saying Gives an opportunity to clarify understanding Shows that you are really engaged in the communication 32

73. Which Response Is the Best Summary? Diabetes Educator 1: “You are really frustrated with all these guidelines for eating.” Diabetes Educator 2: “After all the efforts you have put in the frustration leaves you feeling powerless.” Diabetes Educator 3: “So let’s see, you’ve been through a lot of diets, and some have worked and some have not, but none have helped you keep the weight off. You’re feeling discouraged, and when you’re discouraged you are likely to overeat again.” Is that right?” 34

75. Guiding: exploring motivations and aspirations

76. Following: listening and learning about patientWe will practice these in part two! 35

77. Assessment Tools Confidence/Conviction: linear scale What to look for Confidence or Conviction First? Balance sheet Pros vs. Cons Change vs. No Change 36

78. Motivational Interviewing: Decisional Balance Botelho, 2004

81. Use interviewing techniques and skills to help patient increase willingness to change

82. Explore ambivalence

83. If your patient is motivated to make an action plan, engage in concrete goal setting

84. If not, keep the conversation going, moving forward 39

85. Javier Part Two How does this scenario differ from the first encounter? What skills were used for this encounter? How do you think the provider’s skills style and strategies effected the outcome? https://aade.learnflex.net/CourseDepot/86/Module2/video_sr_b.html Source: AADE

87. Miller, W.R., Rollnick, S. Motivational Interviewing. London: Guilford Press, 1991

88. Botelho, R. (2004). Motivate healthy habits: Stepping stones to lasting change. Rochester, NY: MHH Publications.