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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; ckmachel@aol.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. jwhaley@partnersincorphealth.com.

								
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