Bitesize Behaviour Change workshop



Bitesize Behaviour Change workshop
Bitesize Behaviour
Change Workshop
Judy Leibowitz
Head of Trust IAPT Services
Bev Flint & Chinea Eziefula
Clinical Psychologists
Camden iCope
• Introduce the spirit and principles of the Health
Behaviour Change approach
• Think about applying the principles of HBC in clinical
practice to:
• Work collaboratively with patients
• Understand patients’ motivations
• Recognise and reduce resistance
Hopes & Expectations?
Common Issues/Problems you
Health Behaviour Change
Motivational Interviewing
• developed in addictions field
• applied to wide range of health settings
• patient centred
• active listening
• collaborative
• guiding
A Definition of MI
‘A client-centred, directive method for enhancing
intrinsic motivation to change by exploring and resolving
ambivalence’. Miller & Rollnick (2002)
‘Having a quiet and constructive discussion about
change in which the client drives the process as much
as possible’. Rollnick & Allison (2004)
Summary of MI
• Not just a set of techniques. It is a clinical style – a
way of being with clients
• Provides a way of having conversations about
behaviour change
• These conversations can be tricky
• Aims to resolve ambivalence
• Minimise resistance
• Builds client’s internal motivation to change
MI Evidence-Base – Systematic
Review & Meta-Analysis (2005)
• Concluded that MI outperforms traditional advice
giving in the treatment of a broad range of behavioural
problems and diseases in 80% of the studies (n=19)
• In particular, the magnitude of the decrease of BMI,
systolic blood pressure, blood alcohol concentration
and standard ethanol content is of clinical relevance
and implies that MI can and should be used.
Local MI Evidence!
• Statistically sig reduction in HbA1c levels following self
management programme
• Following Co-Creating training, clinicians reported in
improvement in job satisfaction
• Increased partnership working with patients
• Pressure of time remains…however, participants
reported that they have got better at focussing their
• A need for ongoing learning and support was
Co-creating Health Phase2 Local Evaluation January, 2013. Guys & St
Thomas NHS Foundation Trust & Whittington Health
The Spirit of HBC/MI
Collaborative dancing, not wrestling
of patients’ personal goals,
values, aspirations, concerns,
reasons for change
patients’ autonomy, right to
make the decision not to change
Ambivalence is Normal
• My doctor tells me I will die if I don’t stop smoking but
my father lived to be 97 and smoked all his life
• I need to do some exercise but I am frightened of how
breathless it makes me
• I want to stay well for my children’s sake but I hate
having to take medication every day
• I can’t manage on my own but I don’t want strangers
coming into my home.
Stages of Change (Prochaska & DiClemente, 1986)
Guiding Principles of HBC
Resist the righting reflex
Understand the patient’s motivations
Listen to your patient
Empower your patient
R: Assumptions underpinning the
Righting Reflex
• The patient has the same values/priorities/motivations
as me
• They don’t see there’s a problem
I must show them that what they’re doing is bad
• They don’t care enough
I have to scare them/confront them into caring
• They don’t know how to change/what to do
I need to tell them what to do and how to do it
R: The Righting Reflex and You
Which clinical/work situations make you most
vulnerable to the Righting Reflex?
What happens when you get pulled into this position?
U: Understand your patient/client
L: Listen to your patient/client
• Curiosity and interest
• What would giving up smoking mean for you? What would be
the good things about it / what would be the less good things?
• What would going to a day centre mean for you?
• Understanding patient/client’s meaning, values, what
is important
• You say that having asthma under better control is important
to you, why is that?
• Simple open questions
• What do you know about how your inhalers work?
• What is your understanding of a care package?
• Checking with patients/clients
• Let me make sure I’ve understood you correctly, ……. Is that
• Summarising
• Your breathing hasn’t been too bad lately, but you are
concerned about how you will cope if it gets worse again,
especially since we have talked about discharging you from
the CRS service in a couple of months.
E: Empower your patient/client
• Honouring people’s autonomy, right to make
decisions about change, responsibility for
making change
• Avoiding making assumptions or judgements
• Noticing and reflecting change talk
I’d like to …..
I’m thinking about ….
I’ve already started ….
I wish I could ….
It’s important that I …..
E: Empower your patient/client
Noticing resistance:
What are the signs of resistance?
arguing, discounting, challenging, ignoring, body
language, disagreeing, ‘yes but ….’, pessimism,
reluctance, no eye contact, interrupting, changing the
What causes resistance?
Taking control away
Misjudging readiness to change
The Righting Reflex
E: Empower your patient/client
Reducing Resistance
• Give back control
‘Maybe now’s not the time to talk about exercise, maybe there’s
something more important that you’d like to talk about today?’
• Reflect resistance (in calm, non-judgmental manner)
‘You don’t want to put yourself in a situation that’s going to make
you more breathless’
• Offer double-sided reflections of ambivalence
‘On the one hand you feel anxious about going to a day centre
and on the other hand when you do get out and mix with others
you feel better in your mood.’
• Back off and come alongside your patient/client
Stages of Change (Prochaska & DiClemente, 1986)
Readiness to Change
Offer information if needed, focus on
engaging patient so they will come
back, ‘keep the door open’, avoid
Righting Reflex, elicit and reflect any
concerns about the current behaviour
Use RULE, reflect ambivalence, reflect
change talk, look out for resistance,
avoid Righting Reflex, check out
importance and confidence
Use your tried and tested strategies,
keep using RULE
Information Giving
Elicit – Provide - Elicit
Information Giving
• What do you already know about how your medication
• What do you know about the treatments/care packages
• How do you see the link between smoking cannabis and your
breathing problem?
• Would you like to know more about how exercise can help /
about the day centre?
• Would it be ok if I told you a bit about how to use your inhaler
/ how our service works / what options there are to help you
give up smoking / what the medications do?
Information Giving
• Just the facts
• Avoid judgements, interpretations, the righting reflex
• Slow down, not too much information
• Give in a neutral tone
• Most people find that ….
• Research on this tells us that ….
• Give positive message
• People usually find that doing some gentle exercise makes
their breathing/energy improve vs
• If you don’t get any exercise your health will just get worse
Information Giving
• What do you make of what I’ve said?
• What more would you like to know? (provide)
• What would be the next step for you?
• Don’t say ‘does that make sense’!
Beware the righting reflex
listen and reflect on what they’ve taken from the
information, don’t get into an argument
Watch out for resistance
Information Giving
• Set an agenda and use the identified priority agenda
• Elicit what they already know about that issue
• Provide some information to help the patient make a
decision about whether or not they want to take any
further action
• Elicit what they have taken away from the
information you have provided
Assessing Readiness to Change
Importance x Confidence
= Readiness to Change
Assessing Readiness to Change
• At the moment how important is it for you to stop
smoking/use your medications?
• How confident do you feel that you could stop
smoking/manage this change if you made the
decision to do so?
• On a scale of 0-10 where 0 is not at all important
/confident and 10 is totally important/confident?
Assessing Readiness to Change
• So you’re saying it’s not important at all (0)? Perhaps
there is something else that feels more important for
us to be talking about today? We can always come
back to talking about smoking whenever you feel
ready to do so in the future.
• What makes you rate your confidence at 3 (and not at
• What makes it so important for you to stop smoking
that you give it a 7 out of 10?
Building Readiness to Change
• What would need to happen for you to move up from a 3 to a
• What has helped you when you have given up in the past?
Cons and Pros
• What are the good things about smoking/drinking/exercise?
• What are the things you don’t like about these things?
• What don’t you like about the idea of giving up?
• What are the good things about giving up/making this
Building Readiness to Change
• What might it take for you to decide to try this
medication/reduce your fluid intake?
• What might it take for you to decide to give up
• Suppose you did decide to give up, how might you go
about it?
What next?
• What if anything, do you plan to do now?
• What would be the next step for you?
Last Thoughts
What do you make of this approach?
What do you like?
What concerns do you have?
What one thing do you plan to take away
from today and try out in your clinical work
over the next few weeks?
Rollnick, S., Mason, P. & Butler, C. (1999) Health
Behaviour Change: A Guide For Practitioners.
Churchill Livingstone
Rubak, S., et al (2005) Motivational Interviewing: a
systematic review and meta-analysis. British Journal
of General Practice
Rollnick, S., Miller, W. & Butler, C. (2008) Motivational
Interviewing in Health Care: Helping Patients Change
Behaviour. Guilford Press
Thank you.
Judy, Bev & Chinea

Similar documents