Lecture given to the West of Scotland Pain Group by Dr Marie Prince, Clinical Psychologist on Wednesday 30th October, 2013.

1. Health Behaviour
Change
marie.prince@ggc.scot.nhs.uk
Dr Marie Prince
Clinical Psychologist

2. Overview
•
Readiness for change
•
Components of a behaviour change consultation
1. Establishing rapport
2. Raising difficult issues
3. Assessing readiness to change
 Stages of Change
4. Offer Targeted support
 Key Clinical tasks

3. Learning Outcomes
•
New skill to help patients
•
Increased awareness of patient barriers to change
•
Increased awareness of role of HP in change
•
Ability to link knowledge with patient stage of change
•
Ability to exercise caution with the use of advice
•
Improved “mutuality” in clinical work with patients
• Getting the spirit of the technique…

4. An unhelpful conversation
Clinician: Have you thought about doing more activity?
Client: Yes, many times, but I can’t seem to manage. I am so worried
about injuring myself again. I’m stuck in the house so much these
days.
Clinician: It would certainly help your pain level.
Client: I know, but what can I do, it really hurts when I try to walk more.
Clinician: I have already told you about pacing and building up slowly
and consistently.
Client: Yes but what sort of difference will that make?
Clinician: Over time, you can build it up, learn how much you can
tolerate and start from there.
Client: No, I either do what you tell me and end up in pain or just stay
home and rest, altough even then I am stilll in pain.
Clinician: Yes, but…..
Client: Yes, but...

5. Readiness for Change
• Healthcare often involves helping people to make changes.
• People are in different stages of readiness for change: Stages of
Change
• People can be ‘prescribed treatment’ when they are not ready,
willing or able to commit: Advice fatigue
• People need different kinds of help depending on where they are in
the cycle of change
• Key task is to determine how ready people are to change and to
move them through the process

6. Components of a Behaviour
Change Consultation
1.
Establish rapport
2.
Raise specific issue, e.g. self management
3.
Assess readiness to change
4.
Offer further support targeted at level of readiness to
change

7. 1. Establish Rapport
• Good rapport is essential for an honest discussion about
behaviour change
• Avoid use of certain words e.g. ‘problem’, ‘concern’
• Address other problems or concerns prior to behaviour
change
• Ask open-ended questions that demonstrate concern
and respect for client

8. Open Questions
•
•
•
•
•
Tell me more about…
May I ask you about…?
What concerns you most about…?
Why might you want to become more active?
If you were to try to manage your pain, how might you
go about it?
• What do you think you might do now?
• How can we support you in…..

9. 2. Raising the Issue: Not so Helpful
Abrupt
Judgmental
Confrontational
“You are not active, that is the problem. We really need to discuss you getting it
under control”

10. Raising the Issue: Helpful
Be honest about own agenda
Invite person to express views on subject
Ask permission to discuss topic
“Would you mind spending a few minutes talking about your [this condition] and
whether it might be worthwhile making some changes?
“[This condition] is sometimes linked with your mood/activity level/smoking. I
wonder how you feel this is relevant to you?”
“I notice you have missed a few appointments recently……..how do you feel
about that?”
“I see you have not been taking your medication as prescribed lately...is there
anything I can do to help with this?”

11. Guiding Principles of
Communication
 Advice Giving
 Resist the righting reflex
 Telling
 Understand the client’s
motivation
 Persuasion
 Listen
 Policing
 Empower the individual
 Judging

12. 3. Assessing Readiness
to Change

13. Stages of Change
Prochaska & DiClemente (1986)
Permanent
Exit
Maintenance
Relapse
Action
Contemplation
Decision/
Preparation
PreContemplation

14. Assessing Readiness to Change
Importance
Why should I change?
Personal values and expectations
of the importance of change
Costs of change
Readiness
Confidence
How will I do it?
Self-efficacy
Will I cope?
Can I do it?
Rollnick et al (1999)

15. Formally Assessing Readiness to
Change
The Importance / Confidence
Ruler
1
2
3
4
5
6
7
8
9
10
How important is it for you to engage in self
management/activity at this time? (or smoking/drinking levels)
If you decided right now to make changes to your activity
levels, how confident are you that you would succeed?
The response can elicit CHANGE TALK

16. Change Talk
• Scaling Questions
– Why 6 and not 1 for confidence?
– What would it take to be a 7
– A 2 for importance if fairly low, I am
wondering why…

17. Informally Assessing
Readiness to Change
Listen to the language your
patient uses, to identify their
readiness to change

18. Pre-contemplation, Contemplation
Preparation, Action, Maintenance
“I’m trying hard not to slip back into old habits but it takes a lot of effort”
“I have decided to try to reduce my medication after Christmas”
“I do too much as it is. I don’t need to work on my exercise”
“I would like to work on the mindfulness techniques BUT it’s difficult
and I am so worried that there is a serious problem with my neck, it
is sore and I keep getting tingling.
“I know it’s a slow process but I’ve managed to swim a couple of times
and I am pacing my walking every day.”

19. Explore Importance
• Don’t do anything
• Scaling questions
• Pros & Cons
• Of change
• Of status quo
• A look over the fence
• What would change feel like
• Be curious

20. Explore Confidence
To improve confidence, change must be rated as important.
• Do little more
• Scaling questions
• Brainstorm solutions
• What helped/worked previously?
Re-assess confidence

21. 4. Offer Targeted Support
Key Clinical Tasks
at each
Stage of Change

22. Precontemplation
Raise awareness of a problem
Ask permission to give information if this will not damage rapport;
risks o fmedication use/surgery; alcohol & benefits of change;
rationale for self management
Close discussion but keep door open:
‘Perhaps now isn’t the right time to talk about this. How do
you feel?’
‘I don’t want to push you into a decision. You’ll be the best judge of
whether you want to make any changes’

23. Contemplation
Tipping the balance
Normalise ambivalence
Examine the pros and cons of change
Provide encouragement & support to build confidence
and give hope

24. Decision / Preparation
Choosing between alternative change
strategies
Provide support and encouragement
Offer information and options
Help patients choose between alternative change
strategies
“What would you be willing to try?”
“Which option sounds best to you?”

25. Action
Help to carry out and comply with
change strategies
Focus on small realistic targets / Goal Setting
Offer support/affirmations
Reinforce convictions
Check expectations are realistic to avoid sense of failure

26. Maintenance
Develop new skills to maintain change
Differentiate between lapse and relapse
Identify high risk situations e.g. flare up
Strategies for coping with setbacks
Reinforce importance of accepting chronic pain, not
looking for a cure

27. Relapse
Assist return to change process as soon
as possible
Acknowledge the difficulties of change over time
Provide hopeful and empathic support
Reframe as a ‘learning experience’
Provide support with problem solving:
“What were the positive changes you previously made?”
“What was difficult about it?”

28. Key Clinical Tasks
• Precontemplation
• Contemplation
• Decision/preparation
• Action
• Maintenance
• Relapse
Raise Awareness
Tip the balance
Explore Ambivalence
Pick a strategy
Support & Inform
Support progress
Realistic Goals
Maintenance skills
Relapse planning
Return to change

29. Summary
• Follow the patient
• Be curiously interested
• Use the Stages of Change Model
• Reduce clinician frustration, change is not
your responsibility
• Maintain rapport
• Target your Intervention
• Dance don’t wrestle

30. References
• Cooper, Z., Fairburn, C.G & Hawker, D.M. (2003) CognitiveBehavioural Treatment of Obesity. The Guilford Press.
• Hunt, P. & Hillsdon, M. (1996) Changing Eating & Exercise
Behaviour. Blackwell Science.
• Miller, W.R & Rollnick, S. (2002) Motivational Interviewing:
Preparing People for Change. (2nd edition). The Guilford Press.
• Miller, W.R. (1999) Enhancing motivation for change in
substance abuse treatment. (Treatment Improvement Protocol
[TIP] series no. 35). Rockville, MD: Center for Substance Abuse
Treatment.
• Rollnick, S., Mason, P. & Butler, C. (1999) Health Behavior
Change: A Guide for Practitioners. Elsevier Limited.
• Stott, N & Pill, R.M. (1990) ‘Advise Yes, Dictate No’. Subjects’
views on health promotion in the consultation. Family Practice,
7, 125-131.

31. References
• Improving Health and Changing Behaviour
British Psychological Society, 2008
http://www.abdn.ac.uk/healthpsychology/pub
lications/Health_Trainer_Manual.pdf