Transtheoretical Model of Change

Transtheoretical Model of Change

• Proposed by Prochaska & Velicer in 1997.
• Integrates change processes and principles from different intervention theories using a temporal dimension.
• The temporal dimension used by the model, is the stages of change.

5 Key Health Behaviors

• Physical Activity
• Nutrition
• Smoking
• Sleep
• Stress

Stage 1: Precontemplation

• Individual is not ready to take action within the next 6 months.
• Individual is either uninformed or under-informed.
• Individual has potential maladaptive beliefs.
• Individual is unready, unmotivated, or even resistant.
• Statements include "I can't..." and "I won't...".
• Express genuine empathy and acceptance.
• Focus on understanding the client at a deeper level.
• Appreciate their autonomy.
• Avoid being judgmental.
• Ask permission to reassess later.

Stage 2: Contemplation

• Individual intends to change within the next 6 months.
• Individual is more aware of the pros and cons.
• Individual experiences ambivalence expressing "I might..." or "Maybe one day...".
• Connect to internal motivators, values, and strengths.
• Build on past accomplishments.
• Set small goals related to investigating and thinking about desired change.
• Inquire about the benefits of behavior.

Stage 3: Preparation

• The individual intends to change in the immediate future (within 1 month).
• Expresses "I will..." or "I'm planning to...".
• Have already taken significant action in the past year.
• Examples include joining a gym or consulting a counselor.

Stage 4: Action

• Individual has made specific changes to lifestyle within the past 6 months.
• Expresses "I am...".
• Must attain a criterion that scientists and professionals agree is sufficient.
• Ex: Following physical activity guidelines.
• Keep internal motivators, values, and strengths in mind.
• Engage in social connections.
• Identify appropriate rewards to reinforce behavior.
• Develop contingency plans.

Stage 5: Maintenance

• Individual has made specific changes in lifestyle.
• Individual is working to prevent relapse.
• Expresses "I still am...".
• Reconnect with motivators, values, and strengths.
• Keep the behavior fresh.
• Watch for early signs of relapse.

Stage 6: Termination

• No temptation to return to previous behaviors.
• Has 100% self-efficacy.
• Unswayed by depression, anxiety, boredom, loneliness, anger, or stress.

Assumptions of the Transtheoretical Model

• No single theory can account for all complexities of behavior change. A more comprehensive model will likely require an integration across major theories.
• Behavior change unfolds over time through a sequence of stages.
• Stages are both stable and open to change, similar to how chronic behavioral risk factors are stable yet changeable.
• Without planned interventions, populations may remain stuck in the early stages, lacking inherent motivation to progress through the stages of intentional change.
• A majoriy of at-risk populations are not ready for action and will not be served by traditional action-oriented prevention programs; health promotion can have greater impacts if it shifts from an action paradigm to a stage paradigm.
• Specific processes and principles of change need to be applied at specific stages for progress.
• Chronic behavior patterns are usually under some combination of biological, social, and self-control; stage-matched interventions are primarily designed to enhance self-control.

Health Coaching

• A guide with motivational interviewing skills; foundational to effective health coaching

Four Major Roles of the Physical Therapist in Communication

• Confidant
• Coach, style is guiding, using skills like empathy, respect, acceptance, concreteness
• Communicative Detector
• Teacher

Health Coaching Clients/Patients

• Clients determine their own goals (at least partially).
• Clients use self-discovery and active learning toward their goals.

Health Coaching Physical Therapists

• Help develop intrinsic motivation through behavior change theory, motivational strategies, and effective communication skills.

Self-Management vs. Health Coaching

• Self-management involves independent management of a chronic condition, where healthy behavior is motivated by maintaining function and participation in activities
• Health coaching involves a vision for one's life to include management of a chronic condition, where healthy behavior is motivated by achieving high-priority life goals

Steps for Health Coaching

• This involves a "Trial and Learn" approach, using positive psychology
• Imagining and developing a long-term health/wellness vision
• Setting long- and short-term goals
• Problem solving to overcome barriers
• Identification of resources
• Providing education where information/knowledge is lacking
• Providing support for enhancement of self-efficacy

Physical Therapy Communication: Traditional Approach

• Advice, information, and resources are provided to patients
• Physical Therapists tell the patient WHAT to do and HOW to do it
• Leads to poor adherence and poor outcomes, promotes extrinsic motivation

Physical Therapy Communication: Motivational Interviewing

• A collaborative approach
• Focuses on identifying, exploring, and resolving a patient's ambivalence (or uncertainty) about making lifestyle changes.
• Contributes to greater adherence and positive outcomes, and promotes intrinsic motivation.

Motivational Interviewing Approach Vs. Traditional Approach

• Traditional Treats patients while MI helps patients help themselves
• Traditional Educates while MI Builds motivation and confidence
• Traditional relies on Skills and knowledge of therapist while MI Relies on patient self-awareness/insights
• Traditional strives to have all the answers while MI strive to help patients find their own answers
• Traditional Focuses on the problem while MI Focuses on what is working well
• Traditional Advises while MI Collaborates

Motivational Interviewing: General Principles

• Patients know what is best for themselves. Patients are their own experts.
• Physical therapists must accept that patients make their own choices.

5 General Principles to Practice

• Express empathy through reflective listening
• Develop discrepancy between the client's goals/values and their current behavior
• Avoid argument and direct confrontation
• Adjust to client resistance rather than opposing it directly
• Support self-efficacy and optimism

Motivational Interviewing Acronym: OARS

• Core communication skills include: Open-ended Questions, Affirmation, Reflective Listening, Summarize

OARS Exmaples

• Open-ended Questions, e.g. "How can I help you with ?", "When would you be most likely to?", "What do you think you will gain/lose if you_?", What do you want to do next?

• Affirmation, e.g. "You are clearly a very resourceful person", "You handled yourself well in that situation", "That's a great suggestion", "You had great intentions even though you had some setbacks"

• Reflective Listening, e.g. "You want to exercise yet you don't feel you have the time to do so.", "You were afraid to go to the gym because you felt intimidated.", "You feel like you have the desire to be healthier, but you lack the support needed for change."

• Summarize, e.g. "Here is what I've heard ", "Let me see if I understand so far. You", "So, on one hand you_, but on the other hand you _", "What have I missed?"

• Motivational interviewing is a a collaborative approach to communication that seeks to build intrinsic motivation and promote healthy lifestyle changes.

• Promote "Change Talk" when practicing MI(motivational interviewing)

• Review the 5 general priniciples of MI

• Reviewing the OARS acronym when practicing MI