Michael Vallis, PhD R Psych

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Motivational Interviewing The Challenging
Patient Interactive Case Studies
4th Annual Chronic Disease Self-Management
Conference

• Michael Vallis, PhD R Psych
• Psychologist and Lead, CH Behaviour Change
  Institute
• Associate Professor, Dalhousie University

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Lets Start With What We Know

• The strongest predictor of future behaviour is
  .............?
• PAST BEHAVIOUR!
• What does this say about the likelihood of
  behaviour change?
• NOT!

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And, by the way, the strongest predictor of
changed behaviour is.........?
SELF-EFFICACY
A persons confidence to perform a specific
behaviour in a specific context for a specific
time period and in the face of specific barriers
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Self-Management Support Skills

1. Relationship skills - establishing a change based
   relationship using motivational interviewing
2. Motivational skills - getting to the behaviour
3. Behaviour change skills - making sustainable
   changes
4. Emotion management skills - helping to maintain
   the behaviour

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What Does Self-ManagementSupport Really Mean?

• Fundamental change in the relationship between
  the individual and the HCP
• From
• Expert clinician with uninformed helpseeker
• Let me tell you what you need to do
• Let me tell you what you need to know
• To
• We both have a role to play
• I understand that you will make your own
  decisions and I respect that. Can we have a
  conversation about your health

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Change-Based Relationships

• A helping alliance involves 3 components
• Bond
• Task
• Goal

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Motivational Interviewing

• Ask questions, Minimize statements
• Express Empathy
• Take a curious, nonjudgmental stance
• Learn to sit with ambivalence
• Avoid argument
• Roll with resistance
• Support Self-Efficacy

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Determine Readiness

• Is the behaviour (or lack of it) a problem for
  you?
• Does the behaviour (or lack of it) cause you any
  distress?
• Are you interested in changing your behaviour?
• Are you ready to do something to change your
  behaviour now?

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Getting to the Behaviour
Readiness Assessment
Not Ready
Ambivalent
Ready

• Understanding the behaviour
• Personal meaning
• Seriousness, personal responsibility,
  controllability, optimism

• Expanding on readiness
• Personal/meaningful reasons to change
• Willingness to work hard - connect to principles
• Delay of gratification

Go Right to Behaviour Modification

• Decisional Balance

• Self-Efficacy

• Barriers/Temptations
• Especially social, cultural and environmental

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Working With the BehaviourBehaviour Modification

• Goal Setting
• SMART GOALS
• Specific, measurable, achievable, relevant,
  timely
• Shaping
• Importance of NEXT STEP
• Stimulus control
• Respecting the environment
• Reinforcement Management

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Maintaining ChangeEmotion Management

• Your Task
• Identify
• Educate
• Recommend
• Support

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Managing Emotions

• Dealing with unhealthy coping strategies
• Recognize the value of unhealthy behaviour and
  focus on replacing the function
• Stress Management
• Physical discharge
• Physical calming
• Express emotions
• Seek social support
• Referral for psychological intervention

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• I want to eat what I want, when I want
• I feel fine, I am sure if my diabetes was a
  problem I would feel sick?
• Everytime you follow advice new research gets
  released that says the old way was better

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CASES

• 50 yo single female living with elderly mom
  (depressed drinker), - diabetes COPD dysthymic -
  she is stuck - not moving
• 17 adolescent male - grass - referred from school
  - cocaine and alcohol - struggle to avoid
  situations -hes becoming concerned
• 19 yo referred from probation (drinking/driving)
  - meets regularly - says wants to make changes
  (dont believe him) - are you here because of
  probation - ambivalent but slippery
• 70 yo female - smoker (1ppd) - relapse when
  stressed - motivated - COPD, ca, diabetic and
  bipolar