Michael Vallis, PhD R Psych

Psychologist and Lead, CH Behaviour Change Institute

Associate Professor, Dalhousie University

Motivational Interviewing: The Challenging Patient & Interactive Case Studies

4th Annual Chronic Disease Self-Management Conference

Let’s Start With What We Know

• The strongest predictor of future behaviour is .............?

• PAST BEHAVIOUR!

• What does this say about the likelihood of behaviour change?

• NOT!

And, by the way, the strongest predictor of changed behaviour

is.........?

SELF-EFFICACYA person’s confidence to perform a specific behaviour in a specific context for a specific time period and in the face of specific barriers

Self-Management Support Skills

1. Relationship skills - establishing a change based relationship using motivational interviewing

2. Motivational skills - getting to the behaviour

3. Behaviour change skills - making sustainable changes

4. Emotion management skills - helping to maintain the behaviour

What Does Self-Management

Support Really Mean?• Fundamental change in the relationship between the individual and the HCP

• From

• Expert clinician with uninformed helpseeker

• “Let me tell you what you need to do”

• “Let me tell you what you need to know”

• To

• We both have a role to play

• “I understand that you will make your own decisions and I respect that. Can we have a conversation about your health”

Change-Based Relationships

• A helping alliance involves 3 components:

• Bond

• Task

• Goal

Motivational Interviewing

Ask questions, Minimize statements Express Empathy Take a curious, nonjudgmental stance Learn to sit with ambivalence

Avoid argument Roll with resistance Support Self-Efficacy

Determine Readiness• Is the behaviour (or lack of it) a problem for

you?• Does the behaviour (or lack of it) cause you

any distress?• Are you interested in changing your

behaviour?• Are you ready to do something to change

your behaviour now?

Getting to the BehaviourReadiness Assessment

Not ReadyReady

Go Right to BehaviourModification

Ambivalent

Understanding the behaviour

Personal meaning

Seriousness, personal responsibility, controllability, optimism

Expanding on readiness

Personal/meaningful reasons to change

Willingness to work hard - connect to principles

Delay of gratification

Barriers/TemptationsEspecially social, cultural and environmental

Decisional Balance

Self-Efficacy

Working With the Behaviour:

Behaviour ModificationGoal Setting

SMART GOALS

Specific, measurable, achievable, relevant, timely

Shaping

Importance of NEXT STEP

Stimulus control

Respecting the environment

Reinforcement Management

Maintaining Change:Emotion

Management• Your Task

• Identify

• Educate

• Recommend

• Support

Managing EmotionsDealing with unhealthy coping strategies

Recognize the value of unhealthy behaviour and focus on replacing the function

Stress ManagementPhysical dischargePhysical calmingExpress emotionsSeek social support

Referral for psychological intervention

•“I want to eat what I want, when I want”

•“I feel fine, I am sure if my diabetes was a problem I would feel sick?”

•“Everytime you follow advice new research gets released that says the old way was better”

CASES• 50 yo single female living with elderly mom

(depressed drinker), - diabetes COPD dysthymic - she is stuck - not moving

• 17 adolescent male - grass - referred from school - cocaine and alcohol - struggle to avoid situations -he’s becoming concerned

• 19 yo referred from probation (drinking/driving) - meets regularly - says wants to make changes (don’t believe him) - “are you here because of probation” - ambivalent but slippery

• 70 yo female - smoker (1ppd) - relapse when stressed - motivated - COPD, ca, diabetic and bipolar