Motivating Patients to Change

Unhealthy Behavior!
Dr. Allan R. Dionisio!
Motivational Interviewing and
the Stages of Change!
Based on chapter 13 !
written by Carlo
DiClemente!
From the book
Motivational
Interviewing!
!
Motivation!
n The base word is “motion”—referring to
action or movement.!
n Another word about “motion” is
EMOTION.!
n Knowledge is not enough. !
n Knowledge must be combined with
EMOTION in order to be motivated.!
Think of a behavior that you
have wanted to change for the
longest time, but you haven’t
gotten around to changing.!
PGH Protocol for Resistant Pts!
n Paliwanagan mo.!
n Kulitin mo.!
n Takutin mo.!
n Pagalitan mo.!
n Papirmahin mo.!
What do you do when you can’t
scare them?

(… when other emotions are

greater than fear?)!
6 Stages of Change According
to Prochaska and DiClemente!
n Pre-Contemplation!
n Contemplation!
n Determination!
n Action!
n Maintenance and relapse prevention!
n Termination!
The Objective of the Session!
n The goal is not so much to reach the
Action stage in one session…!
n …but rather to move the patient from his
present stage to the next one.!
n (ideal context--a continuing relationship)!
Know what stage
your patient is in,
then plan accordingly. !
 Specific techniques
(See if you have tried these
already!)!
Pre-Contemplation!
n Patient is not even thinking about
changing his behavior.!
n In fact, they may not see the behavior as
a problem at all.!
Pre-Contemplation!
n The 4 “R”s!
n RELUCTANCE!
n REBELLION!

n RESIGNATION!

n RATIONALIZATION!
Pre-Contemplation!
n RELUCTANCE!
n They do not want to consider change
because of LACK OF KNOWLEDGE or
INERTIA.!
n APPROACH: provide feedback and
information in a sensitive and empathic
manner!
Pre-Contemplation!
n REBELLION!
n They have a heavy investment in the problem
behavior and in making their own decisions.!
n Resistant to being told what to do. Appears hostile.!
n APPROACH:!
• Offer choices!
• Shift some of the energy used to resist into
contemplating change !
Pre-Contemplation!
n RESIGNATION!
n Characterized by lack of energy and
investment!
n They have given up on the possibility of
change and seem overwhelmed by the
problem.!
n APPROACH:!
• Instill hope!
• Explore barriers to change!
Pre-Contemplation!
n RATIONALIZATION!
n Many reasons why the problem is not a
problem or is a problem for others but not for
them.!
n Session feels like a debate!
n APPROACH: Empathy and reflective
listening; the double-sided reflection (“On the
one hand…, but on the other…”)!
Pre-Contemplation!
n Some important considerations:!
n You have to distinguish between
rationalization and informed choice.!
n We cannot assume that “the problem”
means the same to the patient as it does to
us.!
n It is not true that “more is always better”!
• More education, more intense treatment, and
more confrontation does not necessarily produce
more change.!
Contemplation!
n Patient is willing to consider the problem
and is quite open to information and
decisional balance considerations…!
n BUT there is much ambivalence.!
n Remember that contemplation/interest is
not the same as commitment.!
 Contemplation!
n APPROACH!
n Provide information and incentives to change…!
n …but make the information palpable and relevant
to them personally.!
n Deal equally to the hidden “benefits” of
maintaining the behavior (“decisional balance
technique”)!
n Deal equally with the pros and cons of
CHANGING the behavior!
Decisional Balance
Technique!
Prochaska and
DiClementi!
Motivation—observe the use of
emotion in the technique!
n The base word is “motion”—referring to
action or movement.!
n Another word about “motion” is
EMOTION.!
n Knowledge is not enough. !
n Knowledge must be combined with
EMOTION in order to be motivated.!
5 Questions in Series!
n What do you get out of it? !
n What are the disadvantages?!
n What are your goals in life?!
n How does the behavior fit into your goal?!
n If you could change, what would happen?!
 Question 1:
What do you get out of it? !
 Question 2:
What are the disadvantages?!
 Question 3:
What are your goals in life?!
 Question 4:
How does the behavior
contribute to your goals?!
 Question 5:
If you could change, what
would happen?!
 Set a quit date.
Make a plan that fills legitimate
needs and hurdles obstacles.!
5 Questions in Series!
n What do you get out of it?!
n What are the disadvantages of your
behavior?!
n What are your goals in life?!
n How does your behavior contribute to
your goals?!
n If you could change, what would happen?!
Contemplation!
n APPROACH!
n Explore problems with previous attempts to change.!
n Reframe failures into “partial successes”.!
n Emphasize the cyclic nature of change in the stages-
of-change model.!
n Anticipate the barriers to change.!
Determination: Commitment to
Action!
n Hallmark: deciding to take appropriate steps to
stop a negative behavior or start a positive one!
n Assess strength and levels of commitment!
n Anticipate problems and pitfalls!
n Use appropriate techniques. (Enthusiasm is not
a cure for ineptness.)!
Action!
n Provide confirmation of the plan!
n Provide support!
n Provide external monitoring of progress!
n Focus on successful activity (“Progress, not
perfection.”)!
n Reaffirm their decision!
n Offer information about successful models!
n Usually lasts 3-6 months!
 Maintenance, Relapse,
Recycling!
n New behavior is becoming firmly established!
n Threat of relapse becomes less frequent and
intense!
n BUT relapse is always possible!
n APPROACH!
n Provide feedback about length of time needed for
change!
n Help patient become aware of “triggers”!
n Help the patient learn from the relapse!
n Remind them of the cycle of change!