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A Change Plan Worksheet The most important reasons why I want to make this change are: My main goals for my self in making this change are: I plan to do these things in order to accomplish my goals: Specific Action When? Other people could help me with change in these ways: Person Possible ways to help These are some possible obstacles to change, and how I could handle them: Possible obstacles to change How to respond I will know that my plan is working when I see these results: The Spiral of Change The Transtheoretical Model of Change: A Six Stage Process Stage I – Precontemplation: “What me, have a problem? No way.” Unaware of the problem or greatly underestimates it. Not thinking about changing. Actively resistant to the idea of change. No intention to change within the next 6 months. Seeks help under pressure from others. Stage II - Contemplation: “Maybe I need to change something, but I’m not sure what to do” Aware a problem exists. Thinking of changing, but ambivalent. Wants to change in the next six months, but has no specific plan. Not yet made a commitment to action. Despite good intentions, may languish at this stage a long time. Stage III – Preparation: “Yes, there’s a problem and I’m going to change it.” Has already made some unsuccessful change attempts. Thinking about change, intends to take action in the next month. Determines best method(s) for decisive action. Plans to change within a month; Making detailed plans for the change. Stage IV – Action: “I’m doing something about my problem.” Major behavioral change occurs now. Change is activated (for less than 6 months). Biggest risk is relapse. This stage requires considerable time and energy. Stage V – Maintenance: “I’m an old pro now.” Has been regularly practicing the change for 6 months or more. Continues to incorporate change into current lifestyle. Works to consolidate gains and prevent relapse. Remains free of problem behavior, with effective substitutes. Stage VI – Termination: “I’m not even tempted anymore.” The change has been stable for a least one year. New self-image – new behavior and view of self are consistent. (Non-smoker) Lack of temptation – in any situation (no longer desire(s) to smoke, gamble, abuse food, alcohol, drugs, sex or any other target problem behavior) Solid self-efficacy – possesses a new genuine sense of self-confidence that they can function well without engaging in the former problem behavior. A healthier lifestyle – a way of living in which the old behavior plays no part in one’s life Staying in top psychological and spiritual shape – spends time and energy doing things that enhance self-growth, pursuing dreams, hanging out with healthier functioning people. “Committed to life at its fullest” Ancillary Stage VII – Relapse/Recycling: “Whoops, I slipped back into my old habit.” A common occurrence which should be anticipated and resolved. Most relapsers do not give up. Research indicates only about 20% of the population make permanent change on the first try. The majority of people fall back to the contemplation or preparation (not precontemplation) stage Relapse: “Two steps forward and one step back.” A New Paradigm The stages of change represent a new paradigm of behavior change. Health officials will be especially interested in how this paradigm fares in health promotion programs. Some of the comprehensive data that support this paradigm are: 1. The stages of change approach has been cited at being perhaps the most important development in the past decade of research on smoking cessation specifically (JCCP, 1992) and health behavior change generally (Diabetes Spectrum, 1993). 2. The stages of change approach is being used for all of the HIV and AIDS prevention programs directed by the Centers for Disease Control in the United States. It is also implemented in all health promotion programs for dieting and for countering smoking and substance abuse in the National Health Service of Great Britain. 3. This model is not just another action-oriented intervention. It is a new approach to understanding, studying, and optimizing how people change high-risk behaviors. 4. Research has demonstrated with dozens of different problem behaviors that change involves progress through a series of stages, not just a progression from high risk to no risk. 5. This process promotes principles of change that were hitherto unknown. It matches the most powerful processes of change to the needs of individuals at each stage of change. 6. The stages of change approach is designed to match people’s self-change efforts at each and every stage of transition. It is designed to work in harmony with how people change naturally. 7. This format is appropriate for individuals at every stage of change, and not just the 20 percent or fewer who are prepared to take action. 8. Action-oriented health promotion programs typically generate 1 to 5 percent participation rates. Programs based on the new paradigm typically generate 50 to 85 percent participation. 9. Action-oriented programs (aimed, for example, at smoking) typically reduce the rates of risk by 1 to 2 percent. Programs based on this paradigm typically reduce the rates by 12 to 18 percent. 10. Action-oriented programs typically produce high initial success rates followed by dramatic declines in success over time. Programs based on the Transtheoretical Model typically produce lower initial success rates followed by dramatic increases in success over time. 11. Stage-based programs are excellent for people who do not participate in traditional action-oriented programs. 12. Stage-based programs are promising alternatives for people who do not succeed in traditional action-oriented programs. MOTIVATIONAL INTERVIEWING Phase I: Build Motivation to Change (Why) 1. Use OARS Open ended questions Affirm Reflect Summarize (Estimate Level of Readiness to Change) 2. Decrease Resistance: A. Reflections: B. Others: 1. Paraphrase 1. Shift focus 2. Amplified 2. Reframe 3. Double-sided 3. Agreew/twist (Reflect/Reframe) 4. Emphasize personal control 5. Coming Along Side 3. Evoke “Change-Talk” A. Types: B. Methods 1. Disadvantage of 1. Evocative Questions Status Quo 2. Elaborate 2. Advantage of change 3. Importance/Confidence rulers 3. Optimism for change 4. Explore decisional balance 4. Intention to change 5. Query extremes 6. Look back/Look forward 7. Explore goals (values) 4. Responding to Change-Talk 1. Reflect 2. Elaborate 3. Summarize 4. Affirm Phase II: Strengthening Commitment to Change (How) 1. Recapitulation (Grand Summary) 2. Ask Key Questions *Where do we go from here? *What do you want to happen? *What’s the next step? *Where would you like to start? *Where do you see yourself in 2-4 weeks? *What might interfere with this? *Who are your support people? 3. Provide information/Advise with permission *May I offer some possibilities/options? *Are you interested in some suggestions? *Are you open to other considerations? *Would a review of some options be helpful? *Are you looking for helpful information? 4. Negotiate a Treatment Plan *Go to: Change Plan Worksheet (handout 18) 5. End Tasks: Summary Reflection Close the Deal- “Is this what you want to do?” 6. Helpful Hints: *2 Reflections per Question *We can dance or wrestle *Empathy=accurate reflection of clients meaning *Avoid questions or comments that elicit resistance *Melt resistance, evoke change-talk The Spirit of Motivational Interviewing Fundamental approach of Mirror-image approach Motivational Interviewing to counseling Collaboration. Counseling involves a Confrontation. Counseling involves partnership that honors the client’s overriding the client’s impaired expertise and perspectives. The counselor perspectives by imposing awareness and provides an atmosphere that is conducive acceptance of “reality” that the client rather than coercive to change. cannot see or will not admit. Evocation. The resources and motivation Education. The client is presumed to lack for change are presumed to reside within key knowledge insight, and/or skills that the client. Intrinsic motivation for change is are necessary for change to occur. The enhanced by drawing on the client’s own counselor seeks to address these deficits by perceptions, goals and values. providing the requisite enlightenment. Autonomy. The counselor affirms the Authority. The counselor tells the client client’s right and capacity for self-direction what he or she must do. and facilitates informed choice. Four General Principles of Motivational Interviewing Principle 1: Express Empathy. Acceptance facilitates change. Skillful reflective listening is fundamental. Ambivalence is normal. Principle 2: Develop Discrepancy. The client rather than the counselor should present the arguments for change. The change is motivational by a perceived discrepancy between present behavior and important personal goals or values. Principle 3: Roll With Resistance Avoid arguing for change. Resistance is not directly opposed. New perspectives are invited but not imposed. The client is a primary resource in finding answers and solutions. Resistance is a signal to respond differently. Principle 4: Support Self-Efficacy A person’s belief in possibility of change is an important motivator. The client, not the counselor, is responsible for choosing and carrying out change. The counselor’s own belief in the person’s ability to change becomes a self-fulfilling prophecy. Decisional Balance One helpful way of illustrating ambivalence is the metaphor of a balance or seesaw. The person experiences competing motivations because there are benefits and costs associated with both sides of the conflict. There are two kinds of weights on each side of a the balance: one has to do with the perceived benefits of a particular course of action; the other has to do with the perceived costs or disadvantages of the course of action (such as taking medication to lower blood pressure). Decisional balance: Weighing the costs and benefits. A Decisional Balance Sheet Continue to drink as before Abstain from alcohol Benefits Costs Benefits Costs Helps me relax Could lose my Less family conflict I enjoy getting high family Enjoy drinking with More time for my What to do about friends Bad example for my children my friends children Feel better How to deal with Damaging my physically stress health Helps with money Spending too much problems money Impairing my mental ability Might lose my job Losing my time/life Worksite Tobacco Policy Consulting Model Phase I Entry – contract between the consultant and the employer (client). - can be initiated by either side - examples of entry (by the consultant) consultant sends brochure, makes a phone call, or approaches employer at a networking event (by the employer) employer calls consultant or approaches client at a networking event. Initial Assessment – consultant and employer explore the possibilities of a working relationship - employer determines what the consultant has to offer and if the consultant’s services are applicable to what the employer is looking for - consultant determines employer determine whether they can relate well to each other (i.e. communication style, attitude, personality, etc.) - initial assessment can occur during a phone call, at a networking event, or during an onsite visit Contracting – an agreement between the consultant and employer based on the mutual expectations. - the agreement can be a formal written contract or an informal verbal agreement - it can include services to be provided, timeline, costs, etc. - contracting usually occurs during an onsite visit at the organization or during a face to face meeting Diagnosis – gathering information and analyzing it utilizing motivational interviewing - usually begins at the entry with initial observations, intuitions, and feelings - as the consultant begins to work with the organization, a more structured procedure can be used such as individual interviews, small group meetings, surveys, and questionnaires. Phase II Stages of Change Assessment – an assessment of the employer’s goals and the organization’s readiness to change -the assessment is based on the information collected Phase I Pre- Contemplation Preparation Action Maintenance Relapse contemplation Employer has Employer Employer Employer Employer Employer no intention of acknowledges planning to begins enforces does not changing the the need for take action taking policy and enforce policy. Denies change and is toward steps continues to the the problems. thinking about change within necessary identify policy. Resists change. the next move. a month. to resources Knows what to Makes final implement that will do and how to plans but still policy support go about it – needs to change. policy. just not ready to resolve any Begins make a ambivalence. communic commitment Important for ating the employer to upcoming plan change in accordingly policy and and not just identifies come into resources work one day that will and change support the policy. policy Proper change. planning yields a greater success rate. Planning/Intervention – the consultant, utilizing motivational interviewing and coaching techniques, will determine where the organization is on the stage of change chart identify activities and interventions appropriate for that particular stage. Pre- Contemplation Preparation Action Maintenance Relapse contemplation Interventions: Interventions: Interventions: Interventions: Interventions Interventions: 1. Brochure and 1. Brochure 1. Brochure and 1. Brochure and 1. Wellness 1. Onsite Visit policy manual* and policy policy manual* policy manual* Components 2. Follow-up 2. Follow-up manual* 2. Onsite visit 2. Onsite visit (stress, weight calls/letters call 2. Follow-up 3. 3. mgmt., 3. Onsite visit call Presentations** Presentations** exercise)** 3. Onsite visit 4. QE Kit* 4. QE Kit* 2. “Active for 4 5. Pharm. Info 5. Pharm. Info Life” * Presentation** 6. NicAlert/CO 6. NicAlert/CO 5. QE Kit* Monitor Monitor 6. Pharm. Info 7. Quitline, 7. Quitline, 7. ALA,. Websites ALA,. Websites NicAlert/CO 8. Survival Kits 8. Survival Kits Monitor 9. “Active for Life”* *See resource list at end of materials, or contact Debbie Marion or Connie Machel for more information. **Specially developed programs based on SOC and MI, targeted to augment tobacco treatment programs. Contact Debbie Marion or Connie Machel for more information. Phase III Evaluation – a way of determining the significance of the intervention. - evaluation can be a formal pre-test/post-test utilizing surveys and questionnaires or it can be an informal small group meeting with representation from management and the employees discussing “what worked” and “what didn’t work”. Follow-up – once the evaluation has been conducted, the consultant and employer analyze the information collected and determine a follow-up plan. - follow-up can be offering additional cessation services or wellness programs to support the policy. - follow-up can be cycling back through Phase II (Stages of Change) and (Planning/Intervention) in order to formulate a whole new strategy. Phase IV “Phasing Out” – The role of the consultant is to help facilitate the change process through collaborative efforts with the employer in such a way that the organization can “buy into” the change process and gradually manage without the consultant. USING MOTIVATIONAL INTERVIEWING AT THE ORGANIZATIONAL LEVEL TO FACILITATE TOBACCO POLICY DEVELOPMENT PHASE I: Build Motivation to Change – Use OARS *open-ended questions *affirm *reflect *summarize Opening statement/structure *amount of time available *consultant’s role and goals *client’s role *details needing attending to – consent forms, survey, etc. Assess readiness to change Assess current situation regarding policy/tobacco use/organizational environment EXAMPLES Of Open-Ended Questions “What are some of your concerns about employee tobacco use?” “What led you to contact us?” “How do you see us as helping with your concerns?” “What has happened here in the past with tobacco issues?” “What do you see your policy looking like two years from now?” “How do you see your company benefiting from policy/employee cessation?” “What are some barriers to changing tobacco policy at your organization?” EXAMPLES Of Affirmations “It sounds like your organization is really concerned about… …the health of its employees.” …being a socially responsible company.” ”It appears that you have already… …made some moves in a positive direction.” …have a supportive environment in place.” …are committed to dealing constructively with tobacco issues.” EXAMPLES Of Reflections “You have a designated smoking area, and are having complaints about secondhand smoke.” “You’re pleased about what has been accomplished so far, and would like to see all your employees focused on developing healthier lifestyles.” EXAMPLE Of a Summary “So, Mr. X, as I understand your situation at XYZ Corporation, you’ve done some great things with wellness activities which support tobacco cessation. Tobacco is your big concern right now due to secondhand smoke exposure liability issues being raised by nonsmoking employees. You feel you have management support and resources to begin to address the policy issue, but need information on the best way to approach this. What have I left out?” PHASE II – Strengthen motivation to change Decrease resistance – Use reflections Double-sided – “You’re pretty comfortable staying with your current situation, though you are hearing some complaints about secondhand smoke exposure.” Personal content – “You’re right. It’s entirely legal to just stay with designated areas. Some companies decide to take this approach.” Coming along side – “If you do decide at some point to alter your policy, or just want more information, please call. We love working with companies, based on their needs and interests. Evoke Change-Talk – Use these techniques Decisional balance – “So, in the past, it’s been easier to keep designated areas, but the new CIA regulations and awareness of secondhand smoke risks may affect your company’s situation.” Looking back/Forward – “Take a look back to ten years ago when your employees were smoking on the assembly line, then ahead to what your company might look like in five years. What do you see being different for XYZ Corp.?” Explore goals – “What benefits do you see for XYZ and its employees in implementing a tobacco policy?” Query extremes – “So, one choice is to stay with designated areas and still have the liability and health costs, but keep the peace. On the other hand, a tobacco- free policy would eliminate the first two issues, but could cause some resistance while being implemented.” Query extremes – “What if you stay where you are with your policy? What might happen if you moved to tobacco-free?” Respond – Use These Techniques Reflect – “Management has decided they need to act on these complaints.” Elaborate – “So, just having the designated areas is not reducing your health care costs the way you need.” Summarize – “All things considered, then, XYZ has decided to implement some cessation and wellness activities to address the tobacco issue. Affirm – “I think XYZ’s willingness to address its employees’ tobacco use shows concern and a desire to be socially responsible.” TOOLKIT FOR EMPLOYEE CESSATION SERVICES PRECONTEMPLATION PREPARATION FOR TREATMENT Motivation / Company Interest Policy Influences Patient willingness Educate/Motivate Company - part of comprehensive wellness package - short-term benefit – productivity and health costs - employee focused - long-term benefits, improved productivity, attitude, and reduced health costs - treatment is effective - make it user friendly OBTAIN BEHAVIORAL SUPPORT - West Virginia QuitLine - Free Product Phone Support - Access Support Groups in the Community - Provide Value-Added Benefits OBTAIN PHARMACOLOGIC SUPPORT - open formulary - function as outlet for statewide cessation services - prescription vs. non-prescription benefits PROVIDE PROFESSIONAL EXPERTISE - tobacco cessation specialist - cessation counselors - collect data – evaluate risks, benefits, track participation, evaluate success, cost benefit analysis, assess employee satisfaction ENCOURAGE COMPANY BUY-IN - employee availability - employee marketing/promotion - sustained effort - provide space, storage, etc. BUILDING YOUR OWN PARTNERSHIPS - WVDHHR - Wellness Council of West Virginia - Medicaid, PEIA, West Virginia QuitLine - West Virginia University, Department of Family Medicine GENERAL CESSATION APPROACH Education of company / Employee on tobacco use Persistence Enthusiasm Stress Benefits / Appreciate Costs Expertise Responsiveness Commitment to Quality – Success Sell the Plan Problem Solve as a Team ACTION PLAN: Implement Above: See us next year! 11/15/02 REFERENCES/RECOMMENDED RESOURCES STAGES OF CHANGE 1. Prochaska, JO, Norcross, JC, and DiClemente, CC. (1994). Changing for Good: A Revolutionary Six-Stage Program for Overcoming Bad Habits and Moving Your Life Positively Forward. New York: Avon Books. 2. Prochaska, JO, and Norcross, JC. (1994). Systems of Psychotherapy: A Transtheoretical Analysis, 3rd ed. Pacific Grove, CA: Brooks/Cole. 3. DiClemente, CC, and Hughes, SO. (1990). “Stages of Change Profiles in Alcoholism Treatment.” Journal of Substance Abuse, 2, 217-235. MOTIVATIONAL INTERVIEWING 1. Miller, WR, and Rollnick, S. (2002). Motivational Interviewing: Programming People for Change, 2nd ed. New York: Guilford Press. 2. Miller, WR, Zweben, A, DiClemente, CC, & Rychtarik, R. (1992). Motivational enhancement therapy manual: A clinical research guide for therapists treating individuals with alcohol use and dependence. ( Project MATCH Monograph Series, Vol.2). Rockville, MD: National Institute on Alcohol Abuse and Alcoholism. 3. National Institute on Alcohol Abuse and Alcoholism, US Department of Health and Human Services. (1995). Motivational enhancement therapy manual: A clinical research guide for therapists treating individuals with alcohol abuse and dependence (Project MATCH Monograph Series, NIH Publication No. 94-3723). Rockville, MD. 4. Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment, US Department of Health and Human Services (2001). “Quick Guide for Clinicians: Based on TIP 35, Enhancing Motivation for Change in Substance Abuse Treatment.” DHHS Publication No. (SMA) 01-3602. HEALTH PROMOTION AND WELLNESS 1. Rollnick, S, Mason, P, & Butler, C. (1999). Health Behavior Change: A Guide for Practitioners. Edinburgh: Churchhill Livingstone. 2. Skinner, H.A. (2002). Promoting Health Through Organizational Change. San Francisco: Benjamin Cummings. COACHING 1. Crane, T.G. (2001). The Heart of Coaching: Using Transformational Coaching to Create a High-Performance Culture, Revised Ed. San Diego, FTA Press. TOBACCO POLICY /EMPLOYEE CESSATION 1. American Lung Association of West Virginia., Coalition for a Tobacco-Free WV., Wellness Council of WV. “Building a Smoke-Free Worksite/Introduction to Worksite Wellness.” Funded by a grant from WV Dept. of Health and Human Resources, Bureau for Public Health, WV Tobacco Prevention Program. 2. GlaxoSmithKline. (2002) Quit Essentials: Employer Options for Smoking Cessation, Version 2.0. 3. Professional Assisted Cessation Therapy. (2002). Employers’ Smoking Cessation Guide: Practical Approaches to a Costly Worksite Program. CONSULTING/TRAINING/RESOURCES Contact us for further information concerning resources, consulting, or training programs. Debbie Marion and Connie Machel, Co-Directors, Worksite Programs, Wellness Council of West Virginia. Dmarion3168@hotmail.com; email@example.com Barron Drive, PO Box 710, Institute, WV 25112. (304)766-2686. www.wcwv.org. William B. Webb, Ph.D., L.I.C.S.W., M.A.C., Director, Oasis Behavioral Health Services, 689 Central Avenue, PO Box 219, Barboursville, WV 25504. (304)733-3331. www.psychoasis.com. Norman J. Montalto, D.O. Family Medicine, West Virginia University. Director, Freedom From Tobacco Program, Charleston Area Medical Center, 1201 Washington Street East, Suite 108, Charleston, WV 25301. (304) 347-4630. Norman.Montalto@camc.org. Jane Whaley, R.N. Wellness Council of WV Board of Directors, Barron Drive, P.O. Box 710, Institute, WV 25112. (304)766-2686. firstname.lastname@example.org.
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