One of the most valuable contributions psychologists can make to the medical care in rehabilitation is to provide the expertise we have in the area of emotions and motivation by assisting with adherence to essential medical intervention programs. By working with the medical team on matters of primary concern to them you are much more likely to become more integrated with the team. They are the experts on the medical condition and its treatment, and you contribute your expertise as a mental health professional. They prescribe based on medical knowledge and you help see that the prescription is filled.

Motivational Enhancement Therapy (MET) for Medical Conditions provides an excellent context within which to contribute to adherence in a wide range of conditions from COPD to recovery from stroke. It involves these major elements that we will talk about in this series:

o       Stages of change (Prochaska and DiClemente,1984)

o       Motivational interviewing (Miller and Rollnick, 2002)

o       Self-determination theory (Dici and Ryan, 1985)

o       Relapse prevention (Marlatt and Donovan, 2005)

o       Problem solving therapy (Nezu, at. al., 1998)

o       Self-efficacy theory (Bandura, 1997)

o       Self-regulation (Cameron, et. al. 2003)

Miller and Rollnick (2002) define Motivational Interviewing (MI) in this way:

“…a client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence.”

While client-centered, MI is directive, and the goal is to mobilize and channel motivation by focused guided interviews designed to identify client motives and resolve motivational ambivalence. You might say MI and Stages of Change are the yin and yang of motivational enhancement. Prochaska and DiClemente (1984) conducted extensive research to develop what has come to be called the Transtheoretical Model (TTM). The model helps to assess readiness for change and assists in tailoring change to the individual. In their work, a lot of it on one of the most difficult behavior to change—smoking, they found:

o There are five stages of change

o There are ten key processes of change

o Problem solving and decision making involves these elements:

o       Costs and benefits

o       Cons of risk behavior

o       Pros of risk behavior

o Self-efficacy is a major factor in change

o Change is a spiral not a straight line. People move both forward and backward in the natural process of change

It is not a matter of clockwork. Patients may be at different stages for different behaviors.  MI is an excellent counseling style through all five stages. In later stages, once a patient decides to change, the role of the therapist moves to advice, coaching and application of CBT. At all stages we must keep in mind that ambivalence is the natural state and certainty is always rarer than we might like.

Let’s look in more detail at the five stages:

Precontemplators - need information, encouragement, support and a social environment which supports change and may be:

·         Reluctant and thus more likely to be passive.

·         Rebellious and have a heavy investment in risk-behaviors

·         Resigned and may have given up on success with change.

·         Rationalizing and have all the answers to everything.

Contemplators acknowledge problem, are thinking about it but not ready to start. They need continued flow of information and emotional experiences which energize change.

They are:

·         Not yet committed

·         On the edge of tipping the balance one way or another

·         Ready for new information

·         Beginning to accentuate the positives of changing

Preparation means getting ready for action and the therapist must introduce the behavioral methods that can produce effective change. In this stage the therapist must:

·         Help develop a plan

·         Be sure it is good for this patient

·         Continually reassess commitment to move to the action phase

Action is when people actually begin to make the planned changes. They must begin with a commitment (preferably public) and then implement the change. Once they begin the therapist must:

·         Continually build self-efficacy

·         Help avoid traps associated with change

·         Sustain motivation levels

Maintenance, relapse and recycle—the process of changing continues and relapse is always a real possibility. Thus, as Marlatt taught us, we must help people develop plans to address relapse and return to that change cycle. Our work is never done until we have helped the patient develop a plan for exactly how to deal with the kind of backsliding that is part of change in the real world.

In their study of change processes Prochaska found two major types and ten specific methods. I will use my own terms based on my experience for the specific processes:

Experiential change processes:

o       Awareness involves obtaining information on risk issues

o       Affective mobilization involves emotional experiences that energize change and promote motivation

o       Reappraisal involves cognitive/emotional reappraisal of illness and risk behaviors that contribute to illness

o       Impact assessment involves consideration of how risk behavior influences physical and social environment

o       Contextual influence involves changes in the environment that encourage change

Behavioral change processes:

o       Learning alternatives which involves substituting alternatives for the risk behavior

o       Mobilizing support which involves trusting, accepting and using help from others

o       Contingency management which involves changing the context which in turn influences the risk behavior

o       Commitment to change which involves choosing to change and believing it possible

o       Stimulus control which changing the antecedent events which trigger risk behavior

There are important differences between MI with medical conditions and traditional application in addictions:

o       Clients show less resistance and more likely to be ready to change

o       It takes less time to resolve motivational ambivalence

o       The patients’ expectation is that caregivers have expertise and will share that expertise

o       MI may be part of a bigger DM program that involves other professionals playing a very active role

o       In medical conditions we must depend more on TTM so that readiness is carefully weighed

o       In adherence to medical conditions there are two stages:

·        Assessment and understanding of motivational influences on adherence

·        Developing and implementing an adherence plan with the patient

The four primary action principles in MI are:

Principle 1: Express Empathy

·         Acceptance facilitates change

·         Skillful reflective listening is fundamental

·         Ambivalence is normal

Principle 2: Develop Discrepancy

·         Client should present arguments for change

·         Identify discrepancy between current behavior and goals

Principle 3: Roll with the resistance

·         Avoid arguing for change. Prompt the patient to do so.

·         Resistance not directly opposed

·         New perspectives invited

·         The client is the primary source for solutions

·         Resistance is a signal for the therapist to stop and think

Principle 4: Support self-efficacy

·         Belief is important motivator

·         The client must be choosing

·         Counselor must believe the client can change

Resistance is a major and natural element in behavior change. Without it, any changes the patient makes may be very short term. MI involves avoiding the traps and managing resistance. There are three traps to avoid:

·         Take control away. Patients do not like that much.

·         Misjudge importance, confidence and readiness. Check every session.

·         Meet force with force

These strategies are effective:

Strategy 1: Emphasize personal choice and control

·         Never use confrontational style

·         “…it is really up to you…”

·         “…how do you understand what happened to your heart…”

Strategy 2: Continually reassess readiness, importance and confidence

·         Rollnick says: “..resistance is a measure of the extent to which the provider jumps ahead of the patient.”

·         If you think you may have done so stop and check

Strategy 3: Back off and pull along side the patient

·         Assure the patient you understand

·         Use “I wonder if..” as  a stem

Signs of readiness to change include these elements:

·         Decreased resistance

·         Decreased talk about “the” problem

·         Resolve (may be sad)

·         Change talk

·         Questions about change

·         Envisioning a future with change

·         Experimenting with solutions

The therapist must listen carefully for self-motivational statements and seize on these as opportunities for reinforcement and education. There are at least four types:

• Problem recognition such as “Perhaps I have been neglecting my health more than I should” or “Perhaps I should exercise more even with some pain.”

• Expression of concern such as “I am really worried about this” or “How could I have harmed myself by not doing what the nurses ask.”
• Intention to change such as “I want to know my glucose levels every day” or “I want to control this better. What can I do?”
• Optimism about change such as “I know I can do this if I try” or “Other people control their diet and so can I.”

Addressing motivational issues begins by recognizing that ambivalence is always present when human beings face change. In helping patients cope with the challenges of medical conditions, the therapist must use his or her skills to uncover the real reasons for the ambivalence and guide the patient in a very personalized resolution of that ambivalence. That is what Motivational Enhancement Therapy (MET) is all about. Dr. Rick Botelho, in his excellent book called Motivational Practice, (Botelho, 2002) presents six key steps in enhancing and channeling patient motivation:

Step 1 Building Partnership – developing empathy, clarifying roles and responsibility

_ Three essentials in building a working partnership are:

o Develop empathy and understand the patient’s perspective

o Accommodate to the patient’s preferences

o Clarify roles and who is responsible for what

_ Empathy enables the patient to be vulnerable and open themselves up to you so you can

find out more about their real thinking about the illness and better engage them in the

process of change. (Botelho, 2002)

Step 2 Negotiating an agenda- use a problem focused approach to create a shared agenda.

The agenda must reflect the patients values and views or the agenda is a prescription for failure.

_ Key elements in negotiation of an agenda include:

o Get the patient’s agenda out and on the table first

o Clarify matters of urgency to the patient

o Ask permission to integrate your agenda with their agenda

o Agenda must reflect the risk issues from the patient’s point of view. (Botelho,

2002)

Step 3 Assessing Resistance and Motivation – you must carefully evaluate the patient’s

reasons for staying the same versus changing and then continually take the patient’s pulse forchange.

_ A disease-centered assessment involves finding out the patient’s perspective about the

illness and his or her view of risks. They regulate by their view not your view. You do not understand why the patient is doing what they are doing unless you understand the way the patient views their illness.

_ Motivational assessment begins with these areas:

o Clarify differences between your perspective and the patient’s perspective

regarding the illness.

o Understand why the patient embraces the risk behavior

o Explore whether, when, why, what and how much the patient wants to change

Two questions provide information about the importance the patient places on changing healthrelated behavior and the confidence they have about likelihood of succeeding in making in these changes. These should not be seen as static but as dynamic and thus should be regularly reevaluated throughout the course of treatment. The two questions are:

• How do you feel at the moment about changing __________? How important is it to you

to change _____? If 0 was not at all important and 10 were very important, what number

would you give yourself? (Rollnick et. al., 1999)

VeriCare Monthly Memo

December 2006

• If you decide right now to change __________, how confident do you feel about

succeeding with this? If O stands for ‘not confident at all’ and 10 stands for ‘very

confident’ what number would you give yourself? (Rollnick et. al., 1999 )

The kinds of questions the patient asks themselves about importance are:

• Is it worthwhile?

• Why should I?

• How will I change?

• What will be the cost?

• Do I really want to?

• Will it make a difference? (Rollnick et. al., 1999)

With regard to confidence the questions are:

• Can I really change?

• How will I do it?

• How will I cope with X, Y, and Z?

• Will I really succeed? (Rollnick et. al., 1999)

Sometimes patients have so little confidence that to them it doesn’t seem worth even trying. The therapist must build confidence that the patient can successfully change.

The therapist can begin by exploring the importance of change with these questions:

• What would have to happen for it to become much more important for you to change?

• What would have to happen before you seriously considered changing?

• Why have you given yourself such a high score on importance?

• What would need to happen for your importance score to move from your score to 10?

• What stops you moving from your score to 10?

• What are the good things about … (current behavior). What are some of the less good things about --- (current behavior)?

• What concerns do you have about… (current behavior)? (Rollnick et. al., 1999)

The therapist can explore ways to build confidence with these questions:

• What would make you more confident about making these changes?

• Why have you given yourself such a high score on confidence?

• How could you move up higher, so that your score goes to 10?

• How can I help you succeed?

• Is there anything you found helpful in any previous attempts to change?

• What have you learned from the way things went wrong last time you tried?

• If you were to decide to change what might your options be? Are there any ways you know about that have worked for other people?

• What are some of the practical things you would need to do to achieve this goal? Do any of them sound achievable?

• Is there anything you can think of that would help you feel more confident? (Rollnick et. al., 1999 )

Giving information to a patient who does not want the information is useless and can increase resistance to change. The therapist should explore the patient’s view before providing information with these kinds of questions:

• Would you like to know more about…?

• How much do you already know about?

• The test result is…x, what do you make of this?

• What happens to some people is – and-. What about you?

• How do you see the connection between x and y?

• Now that I have given you this information, how does it apply to you?

• Take me through a typical day in your life, and tell me where you (behavior) fits in?...So, on Monday, you woke up, how were you feeling?...Then what did you do?... You’re going a bit fast for me! Can I take you back to when you left the house on Monday morning…What happened then, and how did you feel? (Rollnick et. al., 1999)

Decisional balance

One of the most effective ways to explore the pros and cons that are in the patient’s head is to draw a simple two by two matrix with these elements:

o Write ‘reasons to stay the same’ at the top of one column

�� Write ‘benefits of risk behavior’ in the upper left quadrant

�� Write ‘concerns about change’ in the lower left quadrant

o Write ‘reasons to change’ at the top of the other column

�� Write ‘concerns about risk behavior’ in the upper right quadrant

�� Write ‘benefits of change’ in the lower right quadrant

Then fill in the blank spaces with the patient. Most therapists who use the exercise find it very revealing and opens doors to further inquiry.

Decisional balance involves looking at pros and cons systematically keeping these things in mind:

�� Pros and cons are perceived differently at different stages

�� In precontemplation cons are dominant

�� Pros and cons equalize in contemplation

�� Pros increase in preparation but still some ambivalence

�� Pros dominate in action stage

�� Pros need to stay dominant in maintenance

During the course of therapy it is useful to repeat the simple 2 by 2 exercise as a way to get a snapshot of patient motivation:

Step 4 Enhancing mutual understanding – understanding the patient’s values and perceptions about the illness is essential. It is alright to have a different point of view than the patient as long as we do not try to impose it on the patient.

• You can:

o Explore areas of agreement

o Work toward understanding each other

o Build areas of agreement

o Reduce areas of disagreement (Botelho, 2002)

Step 5 Implementing a plan for change- the plan must reflect the values and beliefs of the patient.

• First re-evaluate the patients commitment to change

• Decide on the focus by considering:

o Stage of change

o Time frame

o Ideal vs pragmatic

• Rick Botelho’s (Botelho, 2002) suggests always starting an exchange of information with

the patient by first eliciting the patient’s knowledge and point of view, then and only then provide the information and always again elicit the patients understanding and point of view on the information provides. He suggests:

o Ask the patient what they know

• “Would you like to know more about….?”

o Provide the information non-judgmentally

• Avoid “you” by referring to other people

• Use language they understand

• Pause regularly to check

• Beware too much detail

o Ask the patient what they think and feel about what they heard

• “What do you make of all this?”

Step 6 Following through

• Help the patient plan for lapses and relapses

• Help the patient mobilize support for continuation of constructive change

• Develop a relapse prevention plan. Lapsing is a natural part of the ongoing process of change and the patient should be aware of that. The relapse planning can build self-efficacy.

The determinants of relapse include both intrapersonal and interpersonal factors:

o Intrapersonal

• Negative emotional states increase risk

• Negative physical states increase risk

• Positive emotional state can even increase risk

• Testing personal control can lead to relapse

• Urges and temptations will happen and the patient needs a plan for

what to do about them

o Interpersonal

• Conflict at work or within the family

• Social pressure from those who do not support the changes the

patient is trying to make

The final step in Motivational Enhancement Therapy (MET) involves helping the patient develop a self-management plan so that they can play an essential role in the management of their illness. The 5-As model (Glasgow et. al, 2002) was developed to provide structure within which therapists can guide the patient in the development of a program for management of risks and symptoms. In this final article in the series we will review the five As and apply them to the example condition of Type II Diabetes.

First let’s briefly define each:

�� Assess- which focuses specifically on the beliefs, behavior and knowledge of the patient about the illness that will be the focus of the plan.

�� Advise- involves providing specific information about the health risks associated with the

illness and about the benefits of change. Motivational Interviewing is an appropriate context and valuable method.

�� Agree- involves collaboration in the setting of goals for reducing risk levels and management of symptoms based on a thorough understanding of such factors and readiness and confidence.

�� Assist- involves the use of systematic problem solving methods, identification of personal barriers to change and helping the patient mobilize environmental support for change.

�� Arrange- involves setting the plan in motion with careful attention to identification of risks for relapse and planning to avoid those risks.

The output of each iteration of the cycle is:

1. List specific goals in behavioral terms

2. List barriers and strategies to address those barriers

3. Specify follow-up plan

4. Share the plan with the treatment team and with the patient’s support network

Assess

While the assessment refers to beliefs, behavior and knowledge related to the illness there are two screening issues that must be addressed:

�� Does the patient present with a personality disorder?

�� Is the patient significantly depressed?

While depression or a personality disorder does not preclude intervention to develop a self-management program these factors must be taken into account in any planning.

One of the most important aspects of this assessment is to evaluation of the patient’s knowledge about and beliefs about their illness. For example, how much does the patient does the patient know about diabetes, the psychological influences and the importance of glucose control? This kind of assessment can use either a structured interview, pencil and paper devices or a combination of both.

The detail required in tracking the history of the illness and its treatment varies somewhat

depending on the illness. In diabetes the more detail the better. Two areas which require

exploration are the current symptoms of the illness being experienced and for diabetics any complications already present such as vision problems or concerns about circulatory problems.

A careful review of risk behaviors such as smoking or potentially damaging dietary patterns (e.g. high carbohydrate levels) is essential since this information will help in setting goals for self-management.

The assessme