Motivating Clients to Change
Behaviors: Stages of Change and
Motivational Interviewing Techniques
Dave Aughey, MD
Jamie Stang, PhD, MPH, RD
Disclosures


We have no relevant financial relationships
with the manufacturers of any commercial
products and/or provider of commercial
services discussed in this CME activity.
We do not intend to discuss an
unapproved/investigative use of a commercial
product/device in our presentation
What is Motivational Interviewing?

Term used for brief encounters with clients in
an effort to promote behavior change

A client-centered approach to promoting
positive changes in behavior based on the
person’s own motivation to change
Nutrition Education and
Motivational Negotiation
Key difference between traditional nutrition
education and motivational negotiation:
In motivational negotiation, information is
presented when participant is ready for it.
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Client asks questions about change methods
Client expresses optimism about change
Client asks what the next step should be
Client experiments with change methods
Why Change Current Practice?

National surveys have identified a need to
change practice
–
–
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Various professions surveyed
Content was specific to child obesity-related risk
factors
ILSI, AAP, ADA and other representatives
Patient Management Skills:
Percent indicating low proficiency
RD
PNP
MD
Addressing
family
conflict
46%
30%
30%
31%
Parenting
techniques
Use of
behavioral
mgmt
strategies
21%
25%
16%
33%
39%
Percent Indicating High Interest in Further
Skills Training
MD
PNP
RD
Eating practices
Physical activity
Sedentary
behavior
Degree of
overweight
Behavior
management
Parenting
techniques
Family conflict
0%
20%
40%
60%
80%
100%
Stage 5
Maintenance
Stages of Change
Stage 4
Action
Stage 3
Determination/
Preparation
Stage 2
Contemplation
Stage 1
Precontemplation
Moving Through Stages of Change

Moving to higher level of readiness to change
requires identifying and addressing key issues
at each step

Client-centered counseling techniques, such as
motivational interviewing, help clients move
through stages of change
–
–
–
Client’s start at different stages
Client’s move through stages at own pace
Counselor provides skills for moving through steps
Stages of Change Model
Pre-contemplation
No plan to change
“What problem?”
Contemplation
Considering change
“Should I change”
Preparation
Taking first steps
“Can I change?”
Action
Changing behavior
“How do I change?”
Maintenance
Sustaining change
“Is it worth it?”
(Prochaska & DiClemente, J Consult & ClinPsychol, 1983)
Step 2
Contemplation
Step 1
Precontemplation
Moving from precontemplation to
contemplation requires the client to
develop:
 Awareness of problem
 Awareness of consequences
Stage 3
Determination/
Preparation
Stage 2
Contemplation
Moving from contemplation to determination
to change requires the client to develop:
 Understanding of current behaviors
 Understanding of desired behaviors
 Discrepancy between values and behaviors
 Belief in own ability to make changes
Stage 4
Action
Stage 3
Determination
Moving from determination to make changes
to action steps requires:
 Identification of personal strengths
 Identification of potential barriers
 Vocalization of intent to change
 Development of plan for change
 Identification of support system
Stage 5
Maintenance
Stage 4
Action
Moving from action to maintenance requires:
 Repeated, successful change efforts
 Sustained behavior change efforts
 Problem solving skills
 Frequent follow up
Processes of Change
Cognitive/Affective
Seek information
Behavioral
Resolve to change
Weigh consequences
Control cues
Consequences on others
Substitute behaviors
Notice social norms
Get rewards
Express feelings
Use social support
Motivational Negotiation

Variety of strategies that elicit “change talk”
and enhance motivation to change behavior

Draws on values and goals of participants
–

Current, past and future behavior is linked to goals
and values
Ambivalence acknowledged as “normal” and
used to explore strategies for change
–
Ambivalence is opportunity, not barrier, to change
FRAMES

Feedback
direct, factual input

Responsibility
you decide

Advice
concrete recommendations

Menu
provide options for change

Empathy
work from the patients’ agenda

Self-Efficacy
empowerment, hope
(Miller & Rollnick, Motivational Interviewing, 1991)
General Principles of Motivational
Negotiation

Reflective listening is THE fundamental skill
required of practitioners

Discrepancy between behavior and personal
goals or values is what leads to change

Resistance signals the need to change current
way of responding to a participant

The participant, not educator, is responsible for
choosing to make specific changes
Minimizing Resistance

Feeling of mutual respect and trust

Minimize autonomy threat by asking
permission and giving choices

Start at the level of the client
–

#1 cause of resistance is when client at one stage
of change but counselor at higher stage of change
Minimize guilt by acknowledging difficulty of
changing and your commitment to assist client
Education and Motivational
Negotiation

In motivational negotiation, information is
presented when participant is ready for it.
–
–
–
–
Client asks questions about change
Client expresses optimism about change
Client asks what the next step should be
Client experiments with change methods
Open Ended Questions

Useful for gathering information from clients

Allows them to provide information they think is
most important or relevant to them
Cannot be answered “yes”, “no”, or “maybe”
Phrases for Open-Ended Questions

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Tell me why…
Tell me about…
Tell me how you have...
I’m interesting in hearing why you…
I’d like to hear your thoughts about…
Explain what you might do…
Give me some examples of…
Open Ended Questions: Practice

Use only open ended questions

Can use a “cheat sheet” until you become
more familiar with a few phrases

Allow adequate silence for response from
participant

Reassure client there is no right or wrong
answer, only their thoughts and ideas
Open-Ended Questions: Practice
 How
mom deals with child’s constant
requests for snacks
 Insert
another example here?
Open-Ended Questions: Practice
 Parental
concerns over intake of
sweetened beverages or excessive
juice.
 Firearm
presence in the home and
how they are stored.
Reflective Listening

Follows an open-ended question

Makes no assumptions about the participant’s
meaning
–
reflects back what you heard the participant say to
elicit more input

Encourages personal exploration

Conveys empathy to client and builds rapport
Reflective Listening

Response is a statement, not a question.

Simplest way is to restate what client said
–

“You are unsure if you could lose weight”.
Deeper reflections try to draw out emotions or
direct client toward positive change statements
–
“Eating fast food is such an important thing to you
that you aren’t sure if you’d be able to cut back to
lose weight”.
Reflective Listening Phrases

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It sounds like you…
It’s difficult/easy for you to…
You realize that…
You’re having trouble/success with…
You understand that…
You feel that…
You do/don’t see the need to …
Let me see if I understand you…
“I want to breastfeed, but I’m afraid I won’t be
able to do it or I won’t be able to leave my child
with anyone, but, I do want the best for my child”
Content reflection
“You want to breastfeed your baby but you have some
concerns about whether that is the best decision for you.”
Feeling reflection
“You are worried that breastfeeding may not be the best
fit for your lifestyle or that it might be too difficult.”
Meaning reflection
“If breastfeeding is hard to learn or if it means you have to
change your schedule a lot, then maybe it isn’t worth it.”
Reflective Listening Choices

When several issues or barriers are brought
up, you will need to focus on one priority area

If reflection on a specific area of concern isn’t
fruitful, try reflecting on another area

“Fishing expeditions” are one way to hit upon
the most important issue of your client
Reflective Listening Practice

“I try to get my daughter to eat different foods,
but she is so picky. If I don’t give her what she
wants she won’t eat anything at dinner. Then
she’ll ask for a snack 10 minutes later.”
–
–
–
Content
Feeling
Meaning
Reflective Listening Practice

“I know that I need to lose weight. But it’s hard
when I see all of my friends eating whatever
they want. I mean, what would they say if I
ordered a salad while they are all eating
burgers and fries? They would make fun of
me.”
Overweight teen
–
–
–
Content
Feelings
Meaning
Reflective Listening Practice

“I have read that vaccinations cause autism. My
nephew has autism and it started right after he
had his shots when he was 2 years old. I’m not
going to take that chance with my baby.” Mother
of 12-month old child
– Content
– Feeling
– Meaning
Reflective Listening Practice

“I try to get my kids to go outside to play but they
would rather watch TV all day. Sometimes I
make them go outside for a half hour but then
they are right back in front of the TV again. And
it’s not so bad, is it? They watch educational
shows and it keeps them from fighting with each
other.” Mother of 4
–
–
–
Content
Feeling
Meaning
Open Ended Question and
Reflective Listening Practice

Counselor: Probe client about

Counselor: Ask client about
We can insert our vignettes here??
Adolescent Developmental Tasks

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WHO AM I?
WHO DO I RELATE WITH?
WHAT IS IMPORTANT?
WHAT IS EXCITING?
Novelty-seeking
Risk-taking
Limit-pushing
Teens develop more complex
thoughts and behaviors

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Goals: short term……………..? long term
Desires: immediate…………...? long term
Rules: external………………..? internal
Values: family/peer…………...? personal
Learn to control impulses
Awareness of adolescent brain
development improves our
motivational skills
The Adolescent Brain

Impulsivity begins to decrease about age 7, but
still continues through adolescence

By age 15, motivated teens can resist
temptation or override impulses similar to
adults (ie 70-80% of the time)
Teen Impulse Control



Impulsivity (seeking thrills & sensations) peaks
around age 15
These “outgoing” behaviors lead to more
friendships (happier, safer, more successful
teens)
The need for novelty gets teens out of the
house and into the World, learning and
mastering
The Adolescent Brain
Challenging parents’ beliefs helps develop an
internalized sense of identity
(appreciating adolescent transformations is not
always for the faint of heart…or easy for
parents and others)
The Adolescent Brain on Dopamine



Adolescence: Peak sensitivity to dopamine
(primes and fires reward circuits)
Aids in learning patterns and decision-making;
results in quick learning and strong response to
social rewards
Teen brain is very sensitive to oxytocin: makes
social relationships very important – bonding,
preference for company of other teens, making
alliances
Building relationships with other
Teens (allies) is biologically driven
and is CRITICAL for successful
development
For the teen brain
Peer exclusion = threat of danger
Being different = peer exclusion

Moving from the safety of home to a
complicated world requires great adaptation,
risk-taking, and courage

Most teens are not impulsive, selfish or
reckless (we just remember the ones who
are)

However, risk-taking is highest between
ages 15-25 and is driven by a “higher need
for reward”
Benefits of adolescent risk-taking

Although adolescent risk-taking can be
construed as dangerous or ill-advised…

These very behaviors provide experiences that
push limits and develop competencies
necessary for thriving and for survival

This adaptation has been necessary for the
successful evolution of the human species
What is our Motivational Goal?

Telling teens what to do denies them the
opportunity to sort things out themselves – to
come up with their own decisions
And this denies them the chance to feel
confident in their own judgement

Telling teens what to do does not help
them!
WE WANT THEM TO DO THE
RIGHT THING THEMSELVES!
5 Principles of Motivation

Empathy

Develop Discrepancy

Avoid Argument

Support Self-Efficacy

Roll with Resistance
Empathy
Understanding and appreciating what the teen
has to let go of in order to change…and what
will it cost?
“My boyfriend will leave me if I don’t have sex.”
“My friends will laugh at me if I don’t drink.”
“Everyone will think I’m weird for liking math.”
“I can’t be with them if I use my inhaler.”
Empathy

Genuine interest in the teen as a person…you
care about their success

Respectful reflective listening
“So, what I hear you saying…”

Positive language and body language

Mirroring the person (nonverbal cues)
Empathy: Responsibility
Emphasize her or his freedom to choose
“It’s up to you; you are free to decide to do this, or not.”
“You’re the only one who can make this happen.”
Empathy: Feedback on
Risk-Taking

Personalized information about problem
behavior and effects or consequences

Non-coercive

Invite feedback
“What do you make of this? How does this fit
or not fit with what you know about yourself”
“Do you think this might concern you?”
What is “Discrepancy”?

It is the difference between where we are
NOW…and Where We Want to Be

Motivating change often starts with
discomfort…the discrepancy in a behavior or
attitude

Discrepancy in what the teen wants becomes
the motivator
How to help the teen “see”
Discrepancy?
“Let me make sure I understand you…”
“So, on one hand you don’t want to get pregnant, right? Yet
you are not using birth control. How does this fit with
your not wanting to get pregnant, right now?”…LISTEN
“Your asthma score is terrible. You’re smoking weed and
cigarettes but not using your inhalers. Help me understand
your thinking?
Discrepancy: Encouraging
Self-Reflection
“So you’re saying you “sometimes” use condoms with your new
girlfriend; do I have this right? Well, why are you using
condoms at all?”
“Why are you only smoking 5 cigarettes a day?”
“Why are you only failing one class instead of four?”
“What are some ways you see yourself handling
this? What will you need to be more
successful?”
Self-Efficacy: Advice

Be supportive and concerned; NOT
authoritarian

Be respectful: “Is it OK if I go over some information
about…?”

Take another’s perspective: “What advice would
you give for another patient in your position? What advice
would you give your parents?”
Inadvertently Sabotaging

“Try to take your pills”

“You “should” take better care to…”

“I know a lot of teens forget their medicine, but you…”

“You can do better, try harder, be smarter…”

You don’t do drugs/have sex/act crazy, do you?”
Change: Menu of Options

Ask teens to identify possible options
“If you are not ready right now to quit smoking, what other
things could you do to become healthier?”
“If you’re not ready to quit, what are ways you might cut
back?”

If the teen can’t think of options: “Is it OK if I
make some suggestions…?”
RESISTANCE IS TOXIC TO
CHANGE
Let go, drop it!
Signs of Resistance
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Denying
Blaming
Excusing
Minimizing
Pessimism
Reluctance
Ignoring, inattention, no answers or
responses, side-tracking
Avoiding Resistance

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Instead of being “directive”, invite discussion
Ask for permission
Use other teens as examples or role models
Monitor nonverbal cues
Reflective listening
Value teens’ perspectives
When an Adolescent is Angry
Underneath ANGER is often FEAR
Be caring and kind, not reactive
Use empathy
Sitting with silence can be comforting
The “poopier” the teen, the greater the
vulnerability
Avoiding Resistance
When we accept and understand a teen’s reality,
s/he becomes free to make decisions
Rather than being trapped by resistance
(Push=Pulled=Shoved=Trapped=No change)
Ambivalence is Normal
Being stuck is OK; it’s an opportunity to
move forward
Feeling Competent
Especially for teens who feel powerless to
change a situation
Help Teens Realize their
Competence

“Think back on all the things you have mastered in your
life….(school, driving, working)…just as you have had
success with these, you are being successful with this.”

“Tell me something you are good at. How did it feel to
succeed?”

“It’s obvious you’re smart and creative and will figure
this out.”
What is Relapse and why it is Good

The person has proven they CAN change and
succeed

Relapse is an opportunity to analyze what went
wrong

Congratulate someone when they relapse…it
will get their attention

Once someone realizes what tripped them up,
s/he can avoid these in the future
Relapse=Opportunity

“So let’s talk about what worked.”

“How/why were you successful?”

“What do you think got in the way of your success?”

“You’re smart…how would you change the situation next
time to be even more successful?”
5 Principle of Motivating Teens
Empathy
Develop Discrepancy
Avoid Argument
Support Self-Efficacy
Roll with Resistance
Advanced Reflective Listening

Shifting Focus
–
Client: “I suppose you are going to tell me that in
order to lose weight I can’t eat anything I like and
that I have to get up at 6 a.m. to go running
everyday.”
–
Practitioner: “To be honest, it’s not up to me to
decide what you will or won’t do to lose weight. My
job is to help you figure out what YOU want to do
and to help you succeed. What is it that you think
you would like to do?”
Advanced Reflective Listening

Reframing
–
Turning clients’ statements into more positive ideas
–
Client: “I’ve been on so many diets and tried all
kinds of exercise, but nothing has worked. I just end
up gaining even more weight.”
–
Practitioner: “The fact that you have tried diets and
exercise in the past tells me that losing weight must
be important to you. You are really motivated to
make some changes.”
Determining Motivations and
Barriers to Behavior Change

“On a scale of 0-10, with 0 being not at all willing
to change, and 10 being complete willingness to
change, how willing are you to suggest that you
and your partner use a condom the next time
you have sex?”
–
“You could have chosen 9 or 10 but you chose 5. Tell
me why you didn’t choose 9 or 10.”
–
“You could have chosen 0 or 1 but you chose 5. Tell
me why you didn’t choose 0 or 1.”
Ambivalence to Change

4 Reasons Why People Are Ambivalent
About Change
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Behaviors seem to “work”
Behaviors seem “normal”
Patients are accustomed to passive role

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fix it for me or give me a pill
Seems too hard to change
Values and Discrepancy

In order to motivate a client, you need to know
what values they find most important, then
relate these to the issue
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Roles as parent, spouse, professional, grandparent
Confident, leadership, independent, respected
Physical appearance, strength, stamina, energy
Popularity, “fitting in”, autonomy, social, accepted
Accepting, giving, patient, happy, healthy, truthful
Wise, bright, brave, creative, successful, hopeful
Core Values
Values For Your Child
Values for You
Values for Your Family
Be healthy
Good Parent
Pleasant mealtimes
Be strong/athletic
Responsible
Healthy habits
Have many friends
Productive
Getting along
Fit in with peers
Good Spouse
Spending time together
Get good grades
Respected
Respectful behavior
Not being teased
Feel good about self
Following rules
Not feeling left out
Healthy
Trust
Fulfill her/his potential
Fit in social group
Have high self-esteem
Feel good about body
Values and Discrepancy

You need to help them discover the link
between their eating and physical activity
behaviors and what is most important to them.
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“How does a lack of exercise affect your child’s
ability to be the energetic, successful person you
would like her to be?”
“Do you think there is any relationship between
losing weight and how confident your child feels?”
“How do you think your unhappiness with your
child’s weight affects your relationship with him?”
Values and Discrepancy

When clients have difficulty seeing relationship
between values and behaviors, try to use
extreme consequence situations.
–
–
“Let’s suppose that you can’t make any changes to
…. How do you think that will affect your health and
your children’s health in the next 5 years?”
“If your son was able to lose 15 pounds, how do you
think his life would be different?”
Values and Behaviors

What values might you use when counseling parents of
a young child on vaccinations?

What values might you use when counseling a teen on
weight issues?

What values might you use when counseling teens on
drug and alcohol use?

What values might you use when counseling parents
about being more physically active with their children?
PROS and CONS

Could you tell me some things you like about ______

What things do you not like about __________

Could you tell me some of the reasons you might want
to change____________

What are reasons you might not want to change _____

What benefits might there be if you change ________

How would changing ____________ affect your family?
PROS and CONS
PROS
If I don’t change
If I do change
CONS
The Final Negotiation

Use a double sided reflection to summarize
session and ask about next step.
–
“You have mentioned some reasons why ,,, On the
other hand, you also talked about … Does that sound
right?”
–
“In thinking about this, is there anything that I can do
to help you?” Or,” What do you think is the next step?”
What about when time is limited?
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Assess stage of change by asking what client
has tried already
Build on previous attempts when determining
area of change
Use 0-10 scale to assess barriers and
strengths
Set goal utilizing info assessed in 0-10 scale
10 mins of counseling CAN make a difference