Motivational Interviewing and Stages of Change_ccby.ppt

Perubahan Organisasi

1. Stages of
Change and
Motivational
Interviewing

2. Behavior Change
Behavior change is rarely a single
event.
Many times we encounter patients
who seem unable or unwilling to
change even after a crisis event.
During the past decade, we have
come to understand that behavior
change passes through identifiable
stages – called The Stages of Change

3. Stages of Change
Stage 1 Pre-contemplative
Stage 2 Contemplative
Stage 3 Preparation
Stage 4 Action
Stage 5 Maintenance & Relapse Prevention

4. Stage One: Precontemplation
During the precontemplation stage,
patients do not even consider
changing.
Smokers who are “in denial” may not
see that the advice applies to them
personally.
Patients with high cholesterol levels
may feel “immune” to the health
problems that strike others.
Obese patients may have tried
unsuccessfully so many times to lose
weight that they have simply given up.
Their position is “I don’t have a
problem” OR “I have tried and failed so
many times why bother”

5. Stage Two: Contemplative
During the contemplation stage,
patients are thinking about change
but are ambivalent “I know I need to
change but…..”.
They may feel a strange sense of loss
even though they understand the
gain.
During this stage, patients assess
barriers (e.g., time, expense, hassle,
fear, “I know I need to, doc, but …”)
as well as the benefits of change.

6. Stage Three: Preparation
During the preparation stage, patients
prepare to make a specific change.
They may experiment with small changes
as their determination to change
increases.
For example, sampling low-fat foods;
calling a treatment center for information.

Switching to a different brand of
cigarettes or decreasing their drinking
may signal that they have decided a
change is needed.

7. Stage Four: Action
The action stage is the one that most
physicians are eager to see their
patients reach.
Patient is actively changing – stopped
smoking, maintaining a new health diet,
etc.
Talk is over – now it’s action.
Encouragement and support is needed
Patient mood is usually lifted during this
stage.

8. Stage Four
Many failed New Year's resolutions show
that if the prior stages have been glossed
over than action itself is often not enough.
Any action taken by patients should be
praised because it demonstrates the
desire for lifestyle change.
Can you see the conflict that can arise
when we do not meet a patient where
they are?

9. Stage Five: Maintenance &
Relapse Prevention
Maintenance and relapse prevention
involve incorporating the new behavior
“over the long haul.”
Discouragement over occasional “slips”
may discourage the change process and
result in the patient giving up.
However, most patients find themselves
“recycling” through the stages of change
several times before the change
becomes truly established.

10. Quiz Time
You have a new client, Mrs. Apple. She
was recently diagnosed with Type II
Diabetes. The physician advises her that if
she can lower her Body Mass Index to the
normal range, her glucose levels will be
normal and stable. When you visit Mrs.
Apple, she doesn’t see her weight as an
issue. According to her, “she is only a little
heavy but she is thinner than her sisters.”
What stage would she be in?

11. As her CHW, you may want to show her
charts of what normal weight ranges look
like, and what weight loss could do for her
health. Are there things that she can’t do
now that she could do if she was at a
lower weight?

12. Quiz Time
On your second meeting, Mrs. Apple tells
you that her sisters are also in poor health,
and she thinks it would be a good idea to
lose some weight. But, she has many
parties to attend in the upcoming months,
and she thinks it would be difficult to not
eat what is being served at the parties.
But, as soon as the summer is over, she is
ready to start a diet.
What stage would she be in?

13. Maybe you can encourage her by
practicing ways that she can say “no” to
another helping of dessert, or letting
others know that she is trying to watch her
diet. Perhaps, you can help her with a
checklist of things that will help her
prepare for her weight loss goal.

14. Quiz Time
You meet with Mrs. Apple again in two
months, and she is ready to start her new
diet. She is excited that her friend also
wants to lose some weight, and are ready
to go on the first of the month.
What stage would she be in?

15. You may want to talk about healthy diets and
balancing meals. Perhaps, you can refer her
to a nutritionist who can help her plan her
new eating habits. Are there exercises that
she likes to do, such as swimming or walking?
Are there any programs in your community
that can help her get an exercise routine in?
Does she like to cook, and if so, are there
some useful cookbooks you can loan her or
have her purchase?

16. Quiz Time
You check in with Mrs. Apple in four
weeks, and she is doing very well on her
diet. She has already lost 7 pounds, and is
taking a 30 minute walk with her dog
every morning. She still likes to have a
bowl of ice cream every night, but she
doesn’t think that is a big deal.
What stage would she be in?

17. Congratulate her on her new routine and
weight loss. Perhaps, you can offer her
healthier alternatives for ice cream, or
encourage moderation. “Wow. You are
doing great! Ice cream is delicious, and l
like to have some too. Perhaps you can
try having it every other night, or switching
to low-fat yogurt?”

18. Quiz Time
When you meet with Mrs. Apple in six months to
check-in with her, she has noticeably lost some
weight. She tells you that she has lost 42 pounds over
the last four months, and only eats a bowl of ice
cream on Friday evenings. She has 20 more pounds
to go to achieve her goal, but she has completely
changed her eating habits and exercise routine—she
now eats six small meals a day, and walks 45 minutes
every morning. She says she is able to play
hopscotch with her granddaughter now without tiring
out too quickly. Her glucose levels are much better,
and her doctor is excited for her.
What stage would she be in?

19. Keep on congratulating her! What great
news and such hard work for getting
closer to her goal! Remind her that her
new routine is what is important, and the
weight loss is just a bonus. Are there any
obstacles or challenges she faces, or is
concerned with in the future, that would
prevent her from continuing?

20. Quiz Time
Four weeks later, you receive a call from
Mrs. Apple. She has gained five pounds
and hasn’t walked in two weeks. She hurt
her knee one day, and fell out of routine.
She doesn’t see the point in continuing, if
it is so easy to gain weight. But, she is
ready to try again and wants to know if
you could come by to take a walk with
her.

21. As her CHW, this may be a good opportunity to
remind her that everyone slips up once in awhile
and that is OK. Remind her of the positives, such
as the other weight she lost and playing with her
granddaughter. And if you are able and
comfortable with the idea, head out as soon as
you can to take a walk with her. It will give you
some time to listen to Mrs. Apple vent a bit, and
help her get back on track. Was hurting her knee
the only problem, or were there other stressors
involved?

22. Family Practice
Helping patients change behavior is
an important role for family
practice.
The concepts of “patient
noncompliance” and motivation
often focus on patient failure.
Understanding patient readiness to
make change, appreciating barriers
to change and helping patients
anticipate relapse can improve
patient satisfaction and lower
physician (and staff) frustration
during the change process.

23. William Miller Ph.D &
Stephen Rollnick Ph.D
Motivational interviewing is non-
judgmental, non-confrontational and
non-adversarial.
The approach attempts to increase the
patients awareness of the potential
problems, consequences and risks
associated with their behavior.

24. Motivational Interviewing
(MI)
A process that helps the patient
move through the stages of
change

25. New Vision for the Future
We help patients envision a better future
and become more motivated to achieve
it.
MI seeks to help patients think differently
about their behavior and ultimately to
consider what might be gained through
change

26. MI uses four general processes to achieve
its ends:
Engaging - used to involve the client in talking
about issues, concerns and hopes, and to establish a
trusting relationship with a counselor.
Focusing - used to narrow the conversation to
habits or patterns that clients want to change.
Evoking - used to elicit client motivation for change
by increasing clients' sense of the importance of
change, their confidence about change, and their
readiness to change.
Planning - used to develop the practical steps
clients want to use to implement the changes they
desire.

27. Direct, Listen, or Guide?

28. Open-ended Questions
Vs.
Closed-ended Questions

29. Example of MI
https://www.youtube.com/watch?v=dm-
rJJPCuTE

30. So What Does This Mean in Our
Practice
The Stages of Change model is useful for
selecting appropriate interventions.
By identifying where a patient is in the change
process, we can tailor the intervention
The focus of the office visit is not to convince
the patient to change behavior but to help the
patient move along the stages of change.
Using the framework of the Stages of Change
model, the goal for a single encounter is a shift
from the grandiose (“Get patient to change
unhealthy behavior.”) to the realistic (“Identify
the stage of change and engage patient in a
process to move to the next stage.”).

31. Practicing Motivational
Interviewing
Ask where the person wants to go – get to
know them a bit
Inform the person about options and see
what makes sense to them.
Listen to and respect what the person
wants and offer help accordingly.

32. Ambivalence
People feel ambivalent about change
I need to loose weight but I hate to exercise; I
need to stop smoking, but I just can’t seem to
do it; I want to get up but it hurts.
Most people want to be healthy AND are
comfortable with familiar routines
Pro’s Con’s

33. Change Talk
Listen for change talk
Desire: I wish I could ____
Ability: I could probably take a walk ___
Reasons: I want to be around for my kids
Need: I’ve got to get back some energy
Commitment: I will, I promise, I am ready
to….

34. Change Talk
When you hear change talk you’re on the
right track
If you find yourself arguing for change
and the person defending the status quo
you’re off course.

35. Practice
Roll play scenario
One is the patient
One is the care provider
One is an observer
Observers take notes and give feedback

36. Use this scenario
Patient expresses desire to stop smoking
He has tried before with some success –
quit for 3 weeks
Motivated by family pressure and….
Wants your help
GOAL
Identify the stage of change and
engage patient in a process to move
to the next stage.

37. This project was funded $3,000,000 (100% of its total cost) from a grant awarded under the Trade Adjustment Assistance
Community College and Career Training Grants, as implemented by the U.S. Department of Labor’s Employment and
Training Administration. Rogue Community College is an equal opportunity employer/program. Auxiliary aids and
services, alternate form and language services are available to individuals with disabilities and limited English proficiency
free of cost upon request.


This work is licensed under a Creative Commons Attribution 4.0 International License.