L19 - Communication Skills for Behaviour Change

• Purpose of Behaviour Change Conversation 

  • PA consultations should:
  • Be a collaborative conversation about behaviour change, not prescriptive
  • Support individuals to make decisions about their PA behaviour 
  • Consultation will be structured differently depending on stage of change 
  • Consultation outcomes are affected by the interaction between you & your client
• Motivational Interviewing - Part 1 

  • A collaborative, person-centred form of guiding to elicit & strengthen motivation to change
  • The individual generates the rationale for change 
  • Autonomous motivation 
  • I think it would be a good idea for you to start exercising → I would like to try & get more exercise (more motivational)

  
• Motivational Interviewing - Part 2

  • Motivational interviewing is all about supporting client’s readiness to change through semi-structured conversations 
  • Why it takes so long to be a good motivational interviewer = creating readiness to change
  • Getting people to feel autonomously motivated
  • Relatedness, social connection 
  • This provides the framework

  
• Spirit of Motivational Interviewing - RULE

  • Resist the righting reflex 
  • Understand client motivations 
  • Listen with empathy 
  • Empower the client 
• Spirit of Motivational Interviewing - RULE

  • Resist the righting reflex 
  • Resist the urge to immediately correct clients if they say something 
  • Giving opportunity to people to talk without being correct & having a debate = creating an environment that is warm & inviting 
  • Understand client motivations 
  • Understand & tap into people's own reasons & values 
• Spirit of Motivational Interviewing - RULE

  • Listen with empathy 
  • Put yourself in your clients shows & non-judgemental understanding off their experiences 
  • PT who was overweight has more empathy & is more successful w/ clients who are overweight 
  • Empower the client 
  • Support clients autonomy by giving them the opportunity to make decisions
• Stages of Motivational Interviewing 

  • Engage → Focus → Evoke → Plan 
  • The order in which we do things is important 
  • Engage 
  • Focus 
  • Evoke 
  • Plan 
  • Nothing can come without engagement - relationships & forming connection is very important

  
• Stages of Motivational Interviewing 

  • Engage → Focus → Evoke → Plan 
  • Engage 
  • Build rapport, making the person feel listened to 
  • Elements of following the client 
  • Set up the collaborative process - forming the relationships 
  • Focus 
  • Hone in on & explore the target behaviour 
  • What does the client want & what might get in the way 
  • Which stage of change are they at? - do you know this already before they come in?

  
• Stages of Motivational Interviewing 

  • Engage → Focus → Evoke → Plan 
  • Evoke 
  • Why does the client want to change? 
  • How confident is the client in change - this leads nicely into the planning stage
  • Future selves? - this builds their self-efficacy
  • Plan 
  • Implementation intentions 
  • Helping to build plans & schedules 
  • Exploring external (social) support - who are they exercising with, are they receiving pressure or support?

  
• Establishing Readiness to Change

  • Importance
  • “On a scale of 1-10, how important is it to you to start exercising?”
  • Can be quite simple like the question above
  • Why did you say 6 & not 1? (elicits positives about exercise)
  • Why did you say 2 & not 5? (elicits negatives & unknowns)
  • Can use this to change their mind on why exercise is important, connect to values 
• Establishing Readiness to Change

  • Confidence 
  • “On a scale of 1-10, how confident are you to start exercising?”
  • A 7 is great, why did you say 7 & not 1? (elicits positive self-statements)
  • You seem to have some confidence, what would help you move from a 4 to a 7? (should explain how to increase confidence)
  • Good opportunities to talk about barriers, is confidence a barrier?
• Establishing Readiness to Change

  • Importance
  • Confidence 
• Ambivalence 

  • Ambivalence = A conflicted state where opposing attitudes or feelings coexist in an individual 
  • eg “I want to exercise but it involves effort”
  • With motivational interviewing, we aim to explore their ambivalence towards change & create discrepancy bw/ current behaviour & values 
  • Getting people to pass the ambivalence 
  • Moving past it can help change the motivation & confidence etc 
• Ambivalence 

  • Importance (why should I change) & Confidence (can I do it) → Readiness (a state of mind)
  • Create ambivalence in a clients’ mind moves them towards change & change talk (readiness to change)
• Interviewing Styles

  • Directing
  • Practitioner completely leads conversation
  • Following
  • Client completely leads conversation
  • Guiding
  • Between the 2 above
  • Is the best for motivational interviewing

  
• Interviewing Styles - Directing

  • The practitioner completely leads the conversation - prescribing what is ‘best’ for the client
  • Sometimes appropriate, but only when asked
  • Sometimes direction is important for certain people
  • But also not honouring self-determination & autonomy (which is important)

  
• Interviewing Styles - Following

  • Allowing the client to completely lead the conversation 
  • Should be used sparingly, & not alone 
  • Clients don’t go anywhere new & can end up in the same patterns 
  • Used carefully when it comes to motivational interviewing

  
• Interviewing Styles - Guiding

  • Somewhere bw/ directing & following 
  • Offering advice when client requests it 
  • Showing client that you’re listening, providing suggestions but allowing them to make decisions 
  • Control the conversation but let the client feel like they are in control

  
• A Continuum of Styles 

  • Directing = informing, you giving the info 
  • Guiding = a mixture of informing, asking & listening 
  • Following = listening, client talking about whatever they want

  
• Practitioner (listening) Skills 

  • We often overestimate our ability to listen
  • We generally only listen w/ about 25% efficiency
  • Effective listening is supported by OARS 
  • We sometimes form opinions before the person is finished talking 
  • Be non-judgmental & listen
  • Focus on the person in front of us - don’t switch off
  • Can be tiring as an interviewer

  
• Practitioner (listening) Skills - 10 Tips to Improve YOUR Listening Skills

  • Stay focused 
  • Detect emotions 
  • Ask questions 
  • Don’t interrupt 
  • Don’t pre-empt
  • Recap key facts 
  • Pen & paper at the ready 
  • Say it again 
  • Watch the stereotype 
  • Be aware of listening barriers

  
• OARS - for Motivational Interviewing

  • Open-ended questions 
  • Affirmations 
  • Reflection 
  • Summarising 
• OARS 

  • Open-ended questions 
  • Get a richer conversation 
  • What, when, how, why, where? (e.g. how do you feel about…)
  • Encourages expression of thoughts, feelings, experiences, values & motivations 
  • Used closed questions sparingly (did you?, have you?, are you?)
• OARS - for Motivational Interviewing

  • Affirmations 
  • Affirming change talk (their belief, reasons for change, intentions) through encouragement 
  • Reflection 
  • Paraphrase what a client says to show clients’ that you’re listening & understanding 
• OARS - for Motivational Interviewing

  • Summarising 
  • Bigger version of reflection, often at the end of a session 
  • Great opportunity to check your understanding of clients experiences 
  • Be on the same page of the client, avoids confusion in the future 
• Open-ended vs Closed Questions 

  • Open-ended questions 
  • How
  • Tell me
  • What
  • Encourages expressions of thoughts, feelings, experiences, opinions, values & motivations 
  • Open-ended questions (on right) = better for rich answers
  • Fuel for the conversation, for it to go deeper & understand why they want to be active

  
• Closed-ended → Open-ended Questions

  • I see here that your GP suggested you come & see me, is that correct? → Tell me, what has led you to decide to see me today?
  • The GP notes say that your blood pressure is above the normal range, that’s not going to be good for your health, is it? → The GP notes say that your blood pressure is above the normal range, how do you feel about that?
  • How about we get you going to the gym 3 times a week & walking on the beach at weekends? → What types of PA do you think you can fit in right now?

  
• Open-ended vs Closed Questions

  • YouTube: Michael Noetel Performance Psychologist 
  • Getting people moving w/ motivational interviewing 
  • Open-ended questions better than closed questions 
• Affirmations

  • Getting people moving w/ motivational interviewing 
  • Saying simple but powerful things such as “that’s fantastic”
  • Can help the self-confidence of client
• Reflections vs Summarisation

  • Getting people moving w/ motivational interviewing 
  • Saying & reflecting what client has said
• Summarisation 

  • Getting people moving w/ motivational interviewing 
  • Spitting facts basically 
  • Taking info & feeding it back to client
• Resistance (& rolling w/ it)

  • You will hear resistance
  • “Yes, but…”
  • Denial, arguing, putting up objections, reluctance 
  • e.g. you agree that PA is good for you?
  • “Yes, but I’m only 40, I’m not going to have a heart attack”
  • “Yes, but I don’t have the time”
• Resistance (& rolling w/ it)

  • You will hear resistance
  • May occur if you have imparted your opinions, used pressuring language, or have misinterpreted their motivation 
  • To resolve, take a step back & rethink the conversation, rather than create a debate 
  • Let's take a step back - on 1 hand you can see how being active might be good for you but on the other hanf you can’t see how you can fit it in right now?
  • Soft skills 
  • Rolling with resistance
• Moving from Why to How

  • Transition from building motivation to planning a course of action 
  • “From what we have just discussed, where does that leave us?”
  • Motivational phase → Volitional phase 
  • Objectives:
  • Setting goals 
  • Building on action plan 
  • Anticipating behaviour
  • Collaboration w/ client 
  • “Let's brainstorm a few ideas on how you could fit more PA into your life”
  • “What can you think of that might get in your way of carrying out your plan?”
• Why does Motivational Interviewing Work? Part 1

  • It's got a lot of evidence, it does work 
  • Building the rapport, which is itself therapeutic (indigenous knowledge has already know this relationship is important for ages but western is only catching up now”
  • Supports the client in understanding their own situation better
  • Doesn’t assume beliefs or attitudes 

  
• Why does Motivational Interviewing Work? Part 2

  • Supports autonomy & autonomous motivation (ie long term change)
  • Acknowledge barriers & works w/ clients to overcome them based on your controlled knowledge 
  • Motivational interviewing is extremely effective, but only when done well - it requires a lot of personal experience & training to get it right

  
• Comparison of Motivational Interviewing

  • Use of open-ended questions
  • No judgement
  • OARS
  • Listening