Supporting behaviour change
This resource will give you an overview of motivational interviewing and provide you with a ‘change toolkit’ to use when discussing change with your clients. It will also sign-post you to other resources should you wish to know more about MI and MECC.
For all health care staff, every interaction with a patient or client is an opportunity to promote health and prevent illness (RCN 2012).
The NHS Future Forum report (2012) states that “Every healthcare professional should use every contact with an individual to help them maintain or improve their mental and physical health and well-being; in particular targeting the four main lifestyle risk factors; diet, physical activity, alcohol and tobacco – whatever their speciality or the purpose of the contact”. This is the basis of the Making Every Contact Count initiative in England.
Motivational interviewing (MI) is an empathetic and supportive counselling style that encourages and strengthens a client's motivation for change. For more information around MI and its co-founder, see Stephen Rollnick.
Research shows that motivational interviewing techniques lead to greater participation in treatment and more positive treatment outcomes. This makes motivational interviewing an excellent tool for using with MECC.
How does motivational interviewing (MI) work?
MI uses a guiding style to engage clients, clarify their strengths and aspirations, evoke their own motivations for change and promote autonomy in decision making (Rollnick et al 2008).
MI is based on these assumptions:
- how we speak to people is likely to be just as important as what we say
- being listened to and understood is an important part of the process of change
- the person who has the problem is the person who has the answer to solving it
- people only change their behaviour when they feel ready - not when they are told to do so
- the solutions people find for themselves are the most enduring and effective.
The four general principles of motivational interviewing:
- R - resist the urge to change the individual’s course of action through didactic means
- U - understand it’s the individual’s reasons for change, not those of the practitioner, that will elicit a change in behaviour
- L - listening is important; the solutions lie within the individual, not the practitioner
- E - empower the individual to understand that they have the ability to change their behaviour. (Rollnick et al 2008)
What makes MI different from other, confrontational approaches?
MI does differ substantially from more aggressive styles of confrontation. It is not:
- arguing with the client who has a problem and needs to change
- offering direct advice or prescribing solutions to the problem without the person’s permission or without actively encouraging the person to make their own choices
- using an authoritative/expert stance that leaves the client in a passive role
- where the health care professional does most of the talking, or only gives information
- imposing a diagnostic label
- behaving in a coercive manner.
What is the evidence that MI works?
Clinical trials have shown that patients exposed to MI (versus treatment as usual) are more likely to enter, stay in and complete treatment, participate in follow-up visits, decrease alcohol and illicit drug use and quit smoking.
Why should I change the way I do things?
It isn't a matter of changing what you have learnt, rather adjusting your skills to be better equipped to deal with your clients. Techniques taken from the motivational interviewing approach can be integrated into your consultation with your clients and this resource provides you with an overview of some of these.
Pre-contemplation stage (contented)
People at this stage usually have no intention of changing their behaviour. They see advantages in their current behaviour or deny they have a problem. Although their families, friends, neighbours, doctors, or co-workers can see the problem quite clearly, the typical pre-contemplator can't.
They may change if there is enough constant external pressure, but once the pressure is removed, they will quickly revert. Pre-contemplators are often avoid thinking about their problem as they feel their situation is hopeless.
Recognising that this is a natural feeling that accompanies this first stage can be a powerful way to motivate clients. They realise that their resistance is natural and that by working through this, and all stages, they can change.
Contemplation stage (considering change)
In the contemplation stage, people acknowledge that they have a problem and begin to think seriously about solving it. They acknowledge the dangers and risks of their current behaviour and consider the pros and cons of changing.
While people in this stage may have vague plans to make changes, they are often not ready to take action yet. The person will still have reasons for continuing their behaviour. Many people remain in the contemplation stage for years.
Preparation stage (acknowledging the benefits of change)
People in the preparation stage have realised that change is beneficial and possible to achieve and start to make concrete plans to change.
Most people in this stage are planning to make changes within the next month and an important first step is to make their intention public.
Although they are committed to action, they may still need to convince themselves that this is the best step. This last-minute resolution is necessary, as people who cut the preparation stage short, lower their chances of success. It's important to develop a firm, detailed scheme of action.
Action stage (ready for change)
The action stage is where people most overtly modify their behaviour and surroundings. They stop smoking, remove all desserts from the house or pour their last beer down the drain.
Maintenance (maintaining change)
The maintenance phase involves successfully avoiding former behaviours and keeping up new behaviours. During this stage, people must deal with temptation in order to avoid relapse but will become more assured that they will be able to continue their change.
In any behaviour change, relapses are a common occurrence. When a patient goes through a relapse, they might experience feelings of failure, disappointment, and frustration.
To support changes in behaviour we must first understand where our client is in their 'change journey'.
The stages of change model can help you to understand this journey. It shows change as a complex process and explains why providing the ‘right advice’ is often not enough (Prochaska et al 1986).
The concept of readiness to change comes from the Stages of Change Model, which shows how individuals are at different stages of change.
The model shows that before any change can take place, a person needs to believe there’s an advantage to changing and must be willing to put an effort into making this happen by deciding when, what and how to do it.
Assessing your client's readiness to change is a critical aspect of MI. Motivation is not static and can change rapidly from day to day. If you can understand where your client is in terms of their readiness to change, you will be better prepared to recognise and deal with their motivation to change.
Why is it important to know my client's attitude to changing?
In order to give effective advice, you need to gauge your client’s understanding of their issue and their interest in changing.
You may need to help your client explore the benefits of making a change and find ways around the potential barriers they may face. To help clients explore the importance of a specific behaviour change and increase their confidence to achieve their goal it helps to:
- start where your client is
- try to see the situation from their point of view
- if they want to change, encourage a realistic first step
- build of their existing strengths and positive past experiences
- use small measurements to assess and track their progress
- people are more likely to change when they for example, when they can see the benefit of changing
- if a person is not ready for a change for example, you should respect their decision
- if a person is unsure about making a change, you could ask them for example: what are the pros and cons of making the change?
- it helps to summarise and consolidate what you have discussed, so you could ask for example: who are you going to ask to support you?
- relapse prevention: You need to explore the potential of relapse and how they could prevent this from happening. You could ask for example: what makes this a good time to change?
The Readiness to change ruler
While readiness to change can be evaluated using the Stages of Change Model, a simpler and quicker way is to use a Readiness to change ruler. This strategy asks clients to vocalise how ready they are to change using a scale of one to ten, where one = definitely not ready to change, and 10 = definitely ready to change. This allows you to immediately know your client’s level of motivation. Depending on where they are, the subsequent conversation will take different directions.
Why not try it on yourself with the change you would like to make?
Try asking your client how confident they feel to attempt a recommended change on a scale of 1 -10. Then ask how them how motivated they feel to make the change on a scale of 1 -10. This ruler can be used to encourage clients to talk about how they have changed, what they need to do to change further, and how they feel about changing.
The following are some examples of clients at different scales on the change ruler.
HCA talking about dieting
HCA: On a scale of one to ten, where one is definitely not ready to change and ten is definitely ready to change, what number best reflects how ready you are right now to diet and exercise more?
HCA: And where were you six months ago?
HCA: So it sounds like you went from not being ready to change to thinking about changing. How did you go from a 'three' six months ago to a 'seven' now?
Client: I enrolled in a group slimming programme and this has helped to motivate me.
HCA: What would it take for you to move to an eight on the scale?
Client: Maybe I could get a friend to come with me, that would really help me to go every week and I'd have someone to chat to during the week.
Health visitor talking about healthier eating
HV: On a scale of one to ten, where one is definitely not ready to change and ten is definitely ready to change, what number best reflects where you are about adding more fruit and vegetables to your family's diet?
HV: Why do you think you are at a 'two'?
Client: I always start with good intentions and buy fruit and veg, but it takes so long to prepare and then the kids just leave it - so it's a waste of money.
HV: Well, unless you can afford a cook, can you think of ways that means they are quick and easy to get ready?
Client: I could prepare meals at the weekend and then freeze them and I could mix the vegetables into mash potato or mince.
HV: What great suggestions! Shall I come and visit you in two weeks?
School nurse talking about sexual health
SN: You use condoms sometimes but not all the time. On a scale of 0 to 10, how likely would you be to change and use condoms every time you have sex, 0 being never and 10 being yes always.
SN: So what does three mean to you?
Client: Making sure that I have condoms and talking about using them before we have sex.
SN: Why don't you talk about using them?
Client: It can be embarrasing to talk about using them.
SN: Well, I could say that it is about looking after ourselves and staying safe.
Talking about change leads to more successful outcomes. Rather than lecturing or telling patients the reasons why they should change, change talk centres around the patient’s responses. These responses usually contain reasons for changing that are personally important.
Below are some examples of the types of questions you can use to keep the conversation flowing, but in a way that provides you, and more importantly your client, with the information they need to change.
Questions to elicit/evoke change talk
There are many ways to ask questions that will get your client to think about their behaviour.
Here are just a few examples:
- “What would be the good things about changing your [problem]?”
- “What would your life be like three years from now if you changed your [problem]?”
- “Why do you think others are concerned about your [problem]?”
Questions to ask if your client is having difficulty changing
As we have discovered, change is hard and there are times when your patient will struggle. You need to focus on being supportive.
These types of questions may help:
- “How can I help you get past some of the difficulties you are experiencing?”
- “If you did decide to change, what would you have to do to make this happen?”
Questions where your client has little desire for change
There will be occasions when, despite your best efforts, you can see your client just does not 'get' that they need to change. In this situation you could then get them to describe in their own words what would be the extreme consequences of continuing on this path, and then what would be the consequences if they decided to change.
Examples of the kind of questions you could use:
- “Suppose you don’t change, what is the worst thing that might happen?”
- “What is the best thing you could imagine that could result from changing?”
Another technique would be to ask your client to compare their current situation and what it would be like to not have the problem in the future.
These types of questions may help:
- “If you make changes, how would your life be different from what it is today?”
- “How would you like things to turn out for you in two years?”
Exploring importance and confidence
Gauging how important a patient considers change and how confident they are about that change, are vital to change talk. These two ratings help us to understand how our patient's feel about the change and to what extent they feel it is possible.
You can continually check these in your conversation with your clients (although don't overdo it) Importance and confidence ratings can be used to get patients to talk about what they would need to do to change. You can use their scores to explore their behaviour.
Examples of how you can explore importance/confidence ratings:
- “Why did you select a score of [insert #] on the importance/confidence scale rather than [lower #]?”
- “What would need to happen for your importance/confidence score to move up from a [insert #] to a [insert a higher #]?”
- “How would your life be different if you moved from a [insert #] to a [higher #]?”
Motivational interviewing techniques can be used to encourage your client to talk about change and reduce their resistance to it.
The following five techniques can be easily integrated into your current approach:
1. Ask open ended questions
If you use too many closed or dead-ended questions it can feel like an interrogation. “How often do you drink?" or "Did you know that smoking can kill you?" Open-ended questions allow patients to tell their stories. It encourages them to do most of the talking. Your goal is to promote further dialogue so you can reflect this back to them.
Here are some examples of open-ended questions:
- Tell me what has happened since we last met?
- What makes you think it might be time for a change?
2. Listen reflectively
We call it reflective listening when you listen to patients then repeat or paraphrase their comments back to them. For example “it sounds like you’re not ready to quit smoking cigarettes”.
Reflections are a way of confirming what the client is feeling and communicate that you understand what they have said.
When a reflection is correct, patients will usually confirm this. If you get the reflection wrong, then this gives the client an opportunity to let you know. For example, “No, I do want to quit, but I am worried about withdrawal symptoms and weight gain”. Your goal is to get your client to state their reasons for changing.
Here is a generic example of reflective listening:
- “What I hear you saying…”
Here is a specific example of reflective listening:
- “I get the sense that you are wanting to change, but you have concerns about the effect this will have on your family.”
Affirmation shows that you understand and empathise with your client's struggles. It allows you to build on their strengths and past successes, improving their sense of well-being. They are best when focused on something your client has done.
Here are some examples of affirmation:
- “I appreciate how hard it gets to have to hear this again.”
- “You have been working hard on improving your diet.”
- “I can see this is upsetting. Thanks for staying through it.”
Clarifying shows your client that you are listening and gives them an opportunity to hear what you think they said, and to respond to it. It also allows you to explain your current understanding and ask for further information if you are confused.
Here are some clarification examples:
- 'So, what you seem to be saying is...'
It helps to summarise and consolidate what you have discussed, so you could ask?
- Who are you going to ask to support you?
- What date have you decided to start?
- What treatment/programme will you use?
Summaries are used to relate or link what patients have already expressed and are an excellent way of expanding the discussion. To summarise effectively, you need to listen carefully to what the client is saying throughout the whole of the conversation. Also, summaries are a good way to end a conversation and can help get a particularly talkative client to move on to the next topic.
Here are some summary examples:
- “It sounds like you are concerned about smoking because it is costing you a lot of money. You also said quitting will probably mean not associating with your friends anymore. That doesn’t sound like an easy choice.”
- “Over the past three months you have been talking about exercising, and it seems that just recently you have started to recognise you are coming up with excuses for not doing it."
5. Elicit self-motivational statements
It is your client that must have the confidence in their ability to change and not you. You can test this confidence by using scaling techniques such as the Readiness to change ruler.
If your client's readiness goes from a low number to a higher number, you can ask follow up questions to see how they feel about the change. If the number is low, you can ask questions to explore what will make them ready.
Here are some examples of eliciting statements to support self-efficacy:
- “It seems you’ve been working hard to quit smoking. That is different than before. How have you been able to do that?”
- “Last week you weren't sure you could go a day without drinking a glass of wine, how were you able to avoid drinking for an entire past week?”
These techniques are not used in isolation, but are entwined throughout the conversation. You will learn which technique to use to get the best outcome.
It can feel frustrating to see the same client again and again, and not see any positive change.
Part of the problem is that we do not correctly gauge whether people are ready to change in the first place.
If a patient is not ready, they should leave it and wait until a more appropriate time. Ploughing on with the process regardless will leave you both frustrated at getting a negative result.
The real challenge is to recognise whether the person is ready to make a change in the first place and to ensure they are making the decisions for themselves. We are so used to telling people what to do that often we don’t recognise that it might be the patient’s own fault when the change process does not work well.
Some of the techniques in this resource will help you to improve your communication skills and your ability to see where you client is on their change journey.
Remember that you are not:
- arguing that a person has a problem and needs to change
- offering advice without a client’s permission
- doing most of talking
- diagnosing a person’s problem
- responsible for making that person change.
If they are not ready to change, leave the door open and part on good terms.