Transcript Document

Delivery Person Centred
Health Behaviour Change Interventions
Val MacDonald
(Health Improvement Specialist , NHS
Highland)
& Catriona Loots
NHS Health Scotland)
Aims of the session
 To explore key concepts underpinning HBC
interventions
 To introduce Motivation Action & Prompt techniques
 To explore the use of Motivational Interviewing to
support interventions
 To offer an opportunity for MI skills practice
Underpinning Competences
• Being aware of professional and ethical
guidelines – for example child protection and
being able to use support
• Knowledge of & skills to work with difference –
being aware of your own values and attitudes
Principles for HBC individual
based interventions
• Person centred care - exploring the whole persons
needs their greatest concerns and what they want to
change, not jumping to conclusions or making
assumptions. They set the agenda.
• Assets-based – understanding clients existing skills
and assets from their environment to support
strategies suitable to their needs.
• Collaborative communication style - working in
partnership with your client empowering them to
solve issues and make decisions
HBC -Brief Intervention
Described as; “ a short, evidence based,
structured conversation about a health
behaviour with a client/patient that seeks in a
non confrontational way to motivate and support
the individual to think about and or/plan a
change in their behaviour”.
Short 5 -20minutes
With an emphasis on personal responsibility!
Discussion Flow Chart
Provide Information/advice M
Enhance Motivation M
Building Confidence M
Setting Goals and Action plans A
Coping Strategies/Relapse
prevention P
• A person-centred information relevant to the
individual and at the appropriate level
• Requested/ with permission (E-P-E)
• Impartial and accurate
Motivation
• Information to assess
personal risk –needs
to be relevant to
person/situation
• Confidence that they
can make changes –
draw on positive
experiences
• Express hope
• Enhancing Motivation
Motivation not Persuasion!
oach
Building Confidence
Enhancing Self Efficacy
• Breaking down tasks
• Mastery Experience
• Vicarious Experience
• Normative influences
Enhancing Motivation
Advantages of current
behaviour
Disadvantages of current
behaviour
Disadvantages of change
Benefits of change
Addressing Barriers
Action on Motivation:
Visioning/ Goal setting
Gadgets for monitoring
Top tips on Change Planning
• Client must identify goals and targets for
themselves.
• Don’t push forward if the client is not ready.
• Identify
– the detail of the desired change.
– the reasons for wanting to change. The client, not
the practitioner must state the case for change.
– the steps for change (SMART objectives).
– people or resources to support the plan.
– obstacles to change and how to overcome them.
– how to determine if the plan has worked.
Prompts and Cues
• Understanding someone’s
situation
• Enlisting family support or
a friend
• Visual reminders
• Avoiding places that
increase the likelihood of
engaging in the behaviour!
Motivational Interviewing
‘Motivational Interviewing is a collaborative,
goal-oriented style of communication with
particular attention to the language of change. It
is designed to strengthen personal motivation
for and commitment to a specific goal by
eliciting and exploring the person’s own reasons
for change within an atmosphere of acceptance
and compassion.’
Miller & Rollnick 2012
Why Motivational Interviewing?
• Motivational interviewing was originally developed in
the field of addiction counselling now used widely
• MI and brief interventions based on MI are being
recommended increasingly in work with anticipatory
care; long-term condition
• MI style seems to lead to more satisfying outcomes for
both practitioners and clients
• Evidence suggest it is more effective than just advice
giving
• The style and skills are generic and can be applied in
many settings, from addictions to mental health, to
criminal justice
Underlying MI…
• People are naturally ambivalent
• Practitioner advocating change increases
resistance
• Evoking person’s own “change talk”
increases likelihood of behaviour change
Individuals are more likely to accept & act
upon that which they voice. Bem, 1972
Techniques (OARS)
• Open-ended questions
• Affirm: try to reinforce anything that builds
confidence
• Reflections
• Summarise
Open-ended questions
• Questions which do not invite one word
answers e.g.
– “What would you like us to talk about?”
– “How did you first start drinking?”
– “What would change in your life if you
stopped smoking?”
– “How do you think that ......is
related to .....?”
Changing closed to open questions
1.
2.
3.
4.
5.
6.
7.
Did you enjoy that film?
Does this feel too hard for you?
Is this really important to you?
How many times do you eat biscuits during the day?
Are you happier now?
Do you often go to the pub in the evenings?
Do you have a cigarette when you have a cup of
coffee?
8. Are you feeling sad about that?
9. How much television do you watch in the evening?
10. Do you enjoy going for walks?
Key tasks in communication
• Asking
• Listening
• Informing
23
Listen – offer reflective
statements
This is the most useful MI skill
- listen, listen, listen, - and practice
reflective listening
Remember to reflect what
lies beneath the surface.
Common Human Reactions to
Being Listened to:
•
•
•
•
•
•
•
•
Understood
Want to talk more
Liking the practitioner
Open
Accepted
Respected
Engaged
Able to change
•
•
•
•
•
•
•
Safe
Empowered
Hopeful
Comfortable
Interested
Want to come back
Cooperative
A good listener
Uses non-verbal communication e.g. focuses
on making eye contact
Asks open questions
Provides accurate, honest information when
asked
Checks and clarifies understanding
26
Reflections
• Reflective statements restate the client’s comments using
language that accurately clarifies and captures the meaning of
what the client is saying.
• The inflection at the end of the reflection should be downward,
otherwise it will sound like a question.
• Shows the client that you have understood what they are
saying.
• Enables the client to amend or confirm what they have said.
• Allows the client to think more deeply about something.
• The practitioner can direct the conversation and focus by
selectively choosing what to reflect.
Simple reflections
• Simple reflection of what has been said
• Paraphrasing: slightly rephrases what has
been said
28
Activity
• Reflective listening – making guesses
Complex Reflections…
Complex reflections typically add substantial
meaning or emphasis to what the client had
said.
They serve the purpose of conveying a
deeper or more complex picture of what the
client had said.
The following things make a reflection
complex….
30
What can make a reflection
complex?
• Adding content (interpretation of feeling)
• Amplification (stronger or weaker)
• Double-Sided (reflect two sides of clients’ viewpoint)
• Reframing (put situation in a different light)
• Verbalization of unspoken emotion
• Emphasize one side (for particular effect)
31
Activity
• Forming reflections
Affirm the client
• Affirmations should be genuine and usually
directed at something specific the client has
done, or an appreciation of strengths or
behaviours.
• e.g. “I can see that caring for your children is
important for you.”
Affirmations include:
• Commenting positively on an attribute
– You’re a strong person, a real survivor.
• A statement of appreciation
– I appreciate your openness and honesty today.
• Catch the person doing something right
– Thanks for coming in today.
• A compliment
– I like the way you said that.
• An expression of hope, caring, or support
– I hope the weekend goes well for you!
Summaries
• In summary statements the practitioner selects
several pieces of client information and combines
them in a summary.
• Can be used to:
– Invite more material
– Check accuracy
– Highlight ambivalence
– Lead into evocative questions and elicit change
talk, e.g.
• “What does this mean to you?”
• “How will you deal with this...?”
• Make a transition to another topic
Summaries can:
• Collect material that has been offered
“So far you’ve expressed concern about your children,
getting a job, and finding a safer place to live”
• Link something just said with something discussed earlier.
“That sounds a bit like what you told me about that lonely
feeling you get”
• Draw together what has happened and transition to a new task
“Before I ask you the questions I mentioned earlier, let me
summarise what you’ve told me so far, and see if I’ve
missed anything important. You came in because you
were feeling really sick, and it scared you……..”
• MI is not incompatible with giving advice
• Rather, it is the context within which the information
is exchanged
• Two circumstances exist when advice should be
given;
• When client requests it
• When client gives permission
Elicit – Provide - Elicit
• Elicit from the person what they already know about changing
the behaviour, or understanding or point of view.
– What do you already know about......?
• Provide information (not advice) about what you know about
changing the behaviour. ASK PERMISION BEFORE YOU DO
SO!
– Is it alright with you if I tell you what I know about......?
• Elicit form the person their reaction to and thoughts about the
information provided.
– How does this make you feel?
– What do you think about those options?
Information Exchange
• May happen at any stage in the MI process. Useful
as part of any health behaviour change consulting.
• Elicit – Provide – Elicit (EPE)
Eliciting Change Talk
•Ask Evocative/Open Questions
– “In what ways does this concern you?”, “How would
you like things to be different?”
•Use the Change Rulers (components of motivation:
importance & confidence)
• Query Extremes
– “What is the worst thing that could happen?” “What
do you hope for most?”
40
• Look Back
– “What did you learn from this?”
• Look Forward
– “If things continue like this what do you see
happening in 2 years?”
– “If you were able to get this under control what would
you like life to be like down the road?”
• Explore Goals and Values
– “What sort of things are most important to you in life?
How does this problem fit into this?”
– “What sort of things do you want to do most with your
life? How does this problem stop you doing that?”
Recognizing change talk (DARN-CAT)
• I would like to take my medicine
• I could take my medicine
• I’d feel better if I took my
medicine
• I’ve got to take my medicine for
my health
• Desire
• Ability
• Reason
• I’m going to take my medicine
• Commitment
42
• Need
How will you know you’ve
got it right?
• The person will be doing most of the talking
• The person will be persuading you of the
need to change
• It won’t feel like a struggle
• You will feel like you are letting go
Dancing, not wrestling
Now over to you!