CSEP-PATH Behaviour Change PDF

Table of Contents Behaviour Change Behaviour Theories and Models Putting Theory into Practice Motivational Interviewing (MI) Brief Action Planning Conclusion References Behaviour Change Canadian Society For Exercise Physiology Physical Activity Training For Health (CSEP-PATH ®) Copyright © 2013, 2...

Table of Contents Behaviour Change Behaviour Theories and Models Putting Theory into Practice Motivational Interviewing (MI) Brief Action Planning Conclusion References Behaviour Change Canadian Society For Exercise Physiology Physical Activity Training For Health (CSEP-PATH ®) Copyright © 2013, 2019, 2021 Canadian Society for Exercise Physiology. CSEP-PATH® is a Registered Trademark of the Canadian Society for Exercise Physiology (CSEP). All rights reserved. Except for use in a review, the reproduction or utilization of this work in any form by any electronic, mechanical, or other means, now known or hereafter invented, including xerography, photocopying, and recording, and in any information storage and retrieval system, is forbidden without the written permission of the publisher. Notice: permission to print out and photocopy the CSEP-PATH® Tools (print and electronic formats) is permitted by users of the Canadian Society for Exercise Physiology – Physical Activity Training for Health (CSEP-PATH®) Resource Manual. Canadian Society for Exercise Physiology 101-495 Richmond Rd | Ottawa ON K2A 4B1 | Canada 1.877.651.3755 | [email protected] | csep.ca | @CSEPdotCA ISBN: 978-1-896900-60-5 Previous ISBNs CSEP-PATH® First Edition 978-1-896900-32-2 (2013), First Refreshed Edition: 978-1-896900-40-7 (2018), Second Edition: 978-1-896900-46-9 (2019) Printed in Canada BEHAVIOUR CHANGE Changing one’s behaviour is challenging. As a result, helping individuals to make regular physical activity a part of their lives can be a complex and often dif cult process. To be effective facilitators of such change, quali ed exercise professionals (QEP) must understand the fundamental in uences on health-related behaviour so that they can appropriately address what might help clients become more physically active. This understanding, along with practical skills needed to provide clients with appropriate guidance and support, will form the foundation of the behaviour change process. Theories of behaviour are useful in informing where best to intervene with clients. In addition, theories provide a basis for evaluating why behaviour change is going well, or where other changes may bene t clients (Lippke & Ziegglmann, 2008). This section provides a basic overview of the main behaviour theories and models used within the physical activity domain, highlights key areas for action or intervention based on the tenets of these theories, and then outlines two approaches that quali ed exercise professionals will nd bene cial as they seek to guide clients to make lasting changes to improve their health and tness. KEY CONCEPTS Theories and models of behaviour used in understanding and promoting physical activity Putting theory into practice using Motivational Interviewing and Brief Action Planning Behaviour Theories and Models Much is known about the broad determinants of health, and the importance of individual’s modi able lifestyle behaviours (e. g., physical activity, diet, tobacco use, alcohol use). To be e ective at guiding clients to make regular physical activity part of their lives, quali ed exercise professionals must recognize that there are many facilitators and barriers when it comes to changing complex behaviours like physical activity. Behaviours occur within the context of very broad in uences spanning from one’s environment all the way down to a person’s genetics (Fisher et al., 2011). This is why using theory is important as it helps to identify the key factors associated with physical activity, and how these can be addressed (Hagger & Chatzisarantis, 2014). For quali ed exercise professionals it is most e ective to attend to how clients think and feel about physical activity, and how they are supported in changing their behaviour to be more physically active; these are the factors that are most easily modi able and have been shown to be key drivers of behaviour change (Heiss & Petosa, 2016; Teixeira et al., 2015). Over the years, a number of important behavioural change theories and models have been developed to describe, predict, and explain how individuals approach health behaviour. Today, the most prominent theories/models used in the context of physical activity are: Social Cognitive Theory (SCT) Self-Determination Theory (SDT) Trans-Theoretical Model (TTM) and Health Action Process Approach (HAPA). These theories focus on deliberate, conscious, re ective thinking as the key processes that lead to a behaviour such as physical activity (Hagger & Chatzisarantis, 2014) - for example, weighing the pros and cons of changing one’s behaviour, or considering how challenging engaging in physical activity might be. Further, the theories discussed in this section re ect two distinct approaches: the cognitive-based approach (i.e., behaviours are controlled by rational cognitive activity), and the stage-based approach (i. e., individuals go through stages to adopt new behaviours) (Sutton, 2008). While other relevant models do exist – including the Schema Theory, the Psychological Continuum Model, the Social Support Model, the Theory of Planned Behaviour, the Enjoyment Model, the Health Belief Model (Sallis et al., 2008), the Integrated Behaviour Change Model, and Identity Theory – the four that will be explored in this section (i. e., SCT, SDT, TTM, HAPA) are reviewed based on their evidence base, their application in intervention studies within the physical activity domain, and their use in professional practice (Buchan et al., 2012). While each of these theories emphasizes slightly di erent constructs, they generally re ect the same broad ideas; that behaviour change is a process not an event, that e ective change must come from within the individual, that intervention strategies must be carefully tailored to each individual’s unique set of circumstances, and that planning is a critical factor in change management. Social Cognitive Theory Social Cognitive Theory (SCT) (Bandura, 1977, 1986, 1998) has emerged as one of the most prominent behaviour change frameworks and its predictive utility in the context of physical activity has been tested across numerous populations (Young et al., 2014). In essence, SCT proposes that people learn through their experiences. It includes the notion of reciprocal determinism, which refers to the dynamic interaction between an individual (who has a particular set of learned experiences), their environment (social context), and their behaviour (response to stimuli). At the core of Social Cognitive Theory (SCT) are four constructs that a ect one's behaviour (Figure 3.1): self-e cacy, outcome expectations (i.e., one's belief in the positive and negative consequences that will occur from engaging in the speci c behaviour), self-regulation (e.g., goal-setting, self- monitoring and planning), and barrier and facilitators (e.g., social support). Consistently, research has shown that self-e cacy is one of the most powerful factors to consider when predicting behaviour (McAuley et al., 2003). Self-e cacy is de ned as the belief in one’s ability to succeed in speci c situations - a concept embedded not only in SCT but also within the other three behavioural theories that are highlighted in this section. A diverse body of research has con rmed self-e cacy’s predictive value within numerous health and physical activity contexts, including weight loss (Young et al., 2016), exercise in cancer survivors, (Bassen-Engguist et al., 2013), exercise in adults with chronic disabilities, (Martin Ginis et al., 2011) and exercise in adolescent girls (Dishman et al., 2004). Self- e cacy has been shown to in uence the goals people set, their ability to persist in the face of obstacles, and their capacity to cope with setbacks and stress. As such, self-e cacy directly in uences behavioural engagement. FIGURE 3.1 Social Cognitive Theory There are four sources of self-e cacy that QEP should be mindful of when working with their clients (Bandura, 1977). Mastery experiences, such as completing a 5km run, are the most robust source of self-e cacy. Success with previous activities that are related to the current task (e.g., running 2km) boost self-e cacy, while past failures erode it. Vicarious experiences, also referred to as modeling, are another source of self-e cacy. Observing a peer succeed at a task can strengthen beliefs in one’s own abilities, particularly if the peer is perceived to possess similar characteristics (e.g., age, gender, health status) as the individual. Social persuasion through credible communication and feedback (e.g., encouragement from a personal trainer) can guide someone through a task or motivate them to make their best e ort (Storer et al., 2014). Lastly, one’s emotional state can also bolster or lessen one’s self-e cacy for physical activity (Ekkekakis et al., 2011). For example, a positive mood can boost one’s self-e cacy for going to the gym, while feeling anxious or stressed can undermine one’s ability to make it to the gym. A certain level of emotional stimulation can create an energizing feeling that can contribute to strong performance and continued participation. Reducing a client’s feelings of stress and anxiety around speci c tasks can also help to bolster their self-e cacy for physical activity. In encouraging clients to embrace regular physical activity, the quali ed exercise professional can focus on building a client’s self-e cacy for physical activity by helping them to set achievable tasks and goals that create success they can build on over time. Four Sources of Self-Ef cacy Mastery Experience. Successful experiences boost self-e cacy, while failures erode it. This is the most robust source of self- e cacy. Vicarious Experience. Observing a peer succeed at a task can strengthen beliefs in one’s own abilities. Social Persuasion. Credible communication and feedback can guide someone through a task or motivate them to make their best e ort. Emotional State. A positive mood can boost one’s self-e cacy, while anxiety can undermine it. A certain level of emotional stimulation can create an energizing feeling that can contribute to strong performance. Reducing stressful and lowering anxiety around speci c tasks can also help.  Self-Ef cacy and Physical Activity Research con rms a strong relationship between self-e cacy (one’s belief in one’s ability to succeed in speci c situations – a concept embedded in most behaviour change models) and health behaviour change and maintenance (Bandura, 1986; Strecher et al., 1986). Behaviour change is seen as a function of a person’s expectations about: outcomes of the behaviour and one’s ability to engage in the behaviour. As such, self-e cacy will in uence a person’s choice of behavioural settings, the amount of e ort they will invest, and how long they will persist in the face of obstacles. For example, an inactive person (i.e., with low physical activity self-e cacy) may feel capable of performing only the most basic tasks in a graded series of tasks (e.g., walk the dog for 10 minutes after dinner each evening at least three times next week). With encouragement, guidance, and by building on success over time, their enhanced self- e cacy can lead them to having little trouble following a much more substantial routine. In contrast, an already-active person will have higher self-e cacy for physical activity and will likely have no trouble following a much more substantial regime from the outset. Self-regulation is an additional construct of SCT that the quali ed exercise professional should target with their clients. Self- regulation involves the ability to monitor and control one’s thoughts, actions, and emotions (Vohs & Baumeister, 2011). It also consists of the avoidance of temptations that distract individuals from long-term goals, and persistence in the face of obstacles (Muraven & Baumeister, 2000). Lapses in one’s behaviour such as missing a scheduled exercise session, are events many individuals will experience. The challenge for the quali ed exercise professional is to work with their clients to develop self- regulatory skills that will lessen the likelihood of a lapse escalating into a relapse (i.e., stopping exercising altogether). Self-regulatory skills include aspects of self-monitoring (e.g., using a diary or log to keep track of one’s walking) scheduling and planning (e.g., forming concrete action and coping plans), setting short and longer-term achievable and measurable goals, and positive self- talk (Table 3.1). TABLE 3.1 Examples of Self-Regulatory Skills SELF- REGULATORY SKILLS EXAMPLE Self- "I use a log to keep track of my walking Monitoring distances each week." Scheduling & "Cold temperatures on Tuesday will alter Planning my regular running plans." Setting Goals "This week, I'll meet my trainer, and attend two classes." "This month, I'll begin training for a 5K." Positive Self- "This is challenging, but I feel supported, Talk and can reach this goal." Self-Determination Theory Self-determination theory (SDT) (Figure 3.2) has been applied extensively to the understanding of physical activity and activity behaviour, and has much to o er in terms of predicting behaviour, understanding behavioural mechanisms, and designing appropriate interventions that increase physical activity participation and adherence (Deci et al., 1985). SDT focuses on the degree to which an individual’s behaviour is self-determined, and the processes through which an individual acquires the motivation to initiate new behaviours and maintain them over time. SDT assumes that individuals are inherently motivated to seek out new challenges and are eager to succeed. SDT also recognizes the importance of one’s social environment on behavioural engagement. Quali ed exercise professionals play an important role in providing an environment that supports clients’ inherent desires to succeed at new challenges (Deci et al., 2000). FIGURE 3.2 Self-Determination Theory In terms of undertaking behaviour change such as starting a physical activity program, SDT contends that individuals have three basic psychological needs: 1. to independently solve problems (autonomy); 2. to master tasks (competence); and 3. to interact socially (relatedness). These three basic needs are present to varying degrees as individuals work through the behaviour change process. During the process of behaviour change, individuals may experience motivation along a spectrum that includes the following:  Amotivation: the individual has no intention or desire to engage in physical activity. External regulation: the individual is motivated to engage in physical activity because of external forces such as pressure from others. Introjected regulation: individuals participate in physical activity without fully accepting it as their own (e. g., to prove they can). Identi ed regulation: the individual consciously values a goal as personally important and is therefore motivated to participate in physical activity because of the goal. Integrated regulation: the individual’s physical activity goals are fully assimilated with self, so they are included in self-evaluation and beliefs about personal needs. It is important to note that integrated regulation is very similar to fully self-determined or intrinsic motivation (in which one embraces physical activity for sheer enjoyment or interest), but the behaviour remains external to the self. Intrinsic motivation: the individual values and participates in physical activity for the sheer enjoyment of it. In applying the constructs of this theory, the quali ed exercise professional will work to bolster a client’s autonomy, competence, and relatedness for regular physical activity by, for example: Promoting the client’s sense of ownership and control over their physical activity Guiding the client through an active examination of their own reasons for becoming physically active Encouraging choice and self-initiation by providing a menu of options for physical activity Encouraging clients to nd activities they enjoy the most and are more likely to integrate into their lives Helping the client to identify realistic goals and providing positive feedback as they achieve success By providing a welcoming environment, a sense of shared experience as the client moves forward or needs to regress  in order to nd success again. While some clients may never reach a point where they value physical activity for the sheer enjoyment of it (i.e., intrinsic motivation), research shows that helping them to see regular physical activity as within their control, important and aligned to their own values can help promote adherence over time (Fortier et al., 2012; Rodgers et al., 2009). Trans-Theoretical Model One of the most popular (and contentious) stage-based models of behaviour change in relation to physical activity is the Trans- theoretical Model (TTM) (Prochaska et al., 1984–1997; Marcus et al., 1992–2003) (Figure 3.3). TTM’s basic premise is that people change habitual behaviours slowly, passing through a series of speci c stages, each characterized by a particular pattern of psychosocial and behavioural changes. Within TTM, individuals are classi ed by their readiness to change into one of ve stages: pre- contemplation, contemplation, preparation, action, and maintenance. FIGURE 3.3 Trans-Theoretical Model Pre-contemplation: the individual is not intending to make a change. People in this stage may say things like, “My Dad never exercised and he lived to 100, so I can too”, or believe they cannot change (“I can’t”, “I’m no athlete”), or be demoralized by past failed attempts (“I’ve tried, but nothing works”). Contemplation: an individual is planning to make a change in the next few months. While aware of the bene ts of change and increasingly dissatis ed with the results of not changing, individuals in this stage have not yet resolved their ambivalence (“I really should exercise, but I never seem to get in gear”). Preparation: the individual has decided to take action and is actively planning to do so in the immediate future. The motivators are de ned and strong and the ambivalence has been addressed (“I’ve been planning to start walking in the mornings. I have holidays next week and thought it would be a good time to start”). The boundary between this stage and  the next is particularly uid as individuals commonly move back and forth between planning action and actually taking action. Action: the individual is committed to the new behaviour and consistently engaging in it (“I’m bicycling three times per week. I have way more energy and sleep better. What a feeling!”). Maintenance: the individual has adopted the new behaviour and done it for several months. The behaviour is rmly established and the individual is con dent in their ability to stick with it. Although several attempts at change are likely before maintenance is reached, the progression through the process may in fact strengthen behaviour change as individuals learn from past regressions. Understanding an individual’s stage of readiness for change can help quali ed exercise professionals in guiding clients through to action and maintenance. The Stage of Change Scale (Marcus et al., 1992a) is a useful tool that the QEP can use to assess client's progress through the stages over time. However, it is important to recognize that: Pre-contemplative clients are unlikely to react well to being told why they should exercise. It will be much more e ective to encourage the client to talk through their own reasons to change (or not) to stimulate a self-exploration of their own bene ts and barriers to change. Contemplative clients also need a good listener who is empathetic and patient as they work through their continued ambivalence to nd their own compelling reasons to change. Here it can be particularly bene cial to focus on bolstering the client’s self-e cacy in their ability to succeed. For clients in the preparation stage, experimenting is important as they try out the new behaviour. Helping clients discover new physical activity experiences they might enjoy (or re-discover things they used to enjoy to  facilitate mastery experiences) can be a very e ective way to help them nd enjoyment and success. For clients in the action phase, the risk of slipping back into the previous stage (i.e., a relapse) remains high in the rst few months. Positive reinforcement of the new behaviour continues to be an important part of the quali ed exercise professional’s intervention toolkit. Changing things up regularly will also help keep it interesting and fresh, and foster variety (Sylvester et al., 2014). The quali ed exercise professional can apply these principles by guiding clients to make informed decisions about physical activity (i. e., working through their own reasons for becoming more physically active and by evaluating options), and by helping them to set realistic and attainable goals and strategies for making physical activity an enjoyable part of daily life. Health Action Process Approach (HAPA) HAPA provides a framework of motivational and volitional constructs that help explain and predict individual changes in health behaviours (Schwarzer et al., 2008), including improving physical activity levels (Biddle et al., 2009). HAPA suggests that the initiation, adoption and maintenance of health behaviours such as physical activity, is a structured process that includes: 1. a motivation phase (i. e., deliberation that leads to the formation of intention), and 2. a volition phase (i. e., during which intentions foster planning). Like many of the previously described behaviour change theories, HAPA includes the constructs of self-e cacy and outcome expectancies as predictors of behaviour change. However, HAPA suggests that intention and volitional factors (e. g., action planning) are the most proximal predictors of change. In other words, good intentions are more likely to be translated into action when people plan when, where, and how to perform the desired behaviour (Carraro & Gaudreau, 2013). Individuals who intend to change (i.e., pre-action stage) are motivated to change but may not have the skills to translate their intention into action. Planning is a key strategy at this point and serves to connect intentions and behaviour. Planning can be divided into action planning (i.e., planning when, where, and how to carry out the intended behaviour) and coping planning (i.e., anticipation of barriers and alternative plans to attain one’s goals in spite of the impediments) (Scholz et al., 2008). Action planning is considered more important for the initiation of health behaviours, whereas coping planning is especially important for maintenance of the behaviour over time (Sniehotta et al., 2006). While self-e cacy is required throughout the entire process, its nature changes from phase to phase, re ecting the di erent challenges posed during goal setting, planning, initiation, action, and maintenance (Figure 3.4). FIGURE 3.4 Health Action Planning Approach: A Process Model to Explain and Predict Health Behaviour Change in Indivduals (Schwarzer et al. 2008.) HAPA may be helpful to QEPs in emphasizing the importance of understanding that clients will be of di erent mindsets. The quali ed exercise professional’s intervention approach can be tailored to the individual client’s mindsets. For example, clients who are pre-intenders may bene t from an examination of their outcome expectancies. They may need to discuss and learn how the new behaviour (e. g., becoming physically active) can yield positive outcomes (e. g., improved well-being, weight loss, fun), as opposed to the negative outcomes that accompany their current behaviours (e. g., gaining weight, having no energy, developing an illness). In contrast, clients who are intenders are not likely to require such a discussion as they have already decided to make a change and have moved into planning to translate their intentions into action. It might be valuable to help clients who are intenders to set realistic and measurable goals. Finally, clients who are already in the action phase may not require much more than re nement of their action plans to achieve new goals, prevent relapses, and promote variety for sustained participation. Putting Theory into Practice While each of the theories, models, and intervention approaches described in this section emphasizes slightly di erent constructs, they generally re ect the same broad ideas about behaviour change. A number of commonalities are of particular relevance to the QEP. First, each of the theories is founded on the notion that the individual is in control of their own behaviour and that behaviour change must come from within. This puts the QEP in the role of collaborator and partner to clients as they work through a rational decision-making process about whether and how best to make regular physical activity part of their lives. In short, the quali ed exercise professional acts as a motivational guide as the client examines the bene ts of changing their behaviour, as well as the obstacles to change, and conceives solutions for addressing those obstacles. Another important commonality between the theories is that addressing the in uences on an individual’s behaviour can take time, and as a result, behaviour change is a process (not an event). Most people won’t be able to dramatically change entrenched behaviours all at once. The quali ed exercise professional must therefore carefully consider each client’s current physical activity and sedentary behaviour habits along with their thoughts, feelings, and support around these behaviours. This information will assist the QEP in identifying an appropriate initial prescription that is manageable for each client and hence, useful in shaping behaviour change. Such an approach o ers the quali ed exercise professional opportunities to reinforce new behaviours (e. g., by celebrating the client’s successes along the way), and to help build the client’s self- e cacy and competence to take on progressively more ambitious challenges towards their ultimate goal. The four theories discussed in this section: Social Cognitive Theory (SCT) Self-determination Theory (SDT) Trans-Theoretical Model (TTM) and Health Action Process Approach (HAPA), aim to understand and explain behaviour. Although helping clients change their behaviour will be challenging, using theory as the starting point to promote physical activity is key to igniting behaviour change (Stacey et al., 2015). However, in order to put theory into practice, QEPs need to understand the techniques or approaches that may be most e ective in helping clients recognize and reconsider their behavioural choices. The way in which quali ed exercise professionals work with clients, what they say, and the techniques they choose to use to assist their clients in nding reasons to change are equally important (Fortier et al., 2016; Michie et al., 2008). For QEPs who wish to be as e ective as possible in helping their clients achieve lasting change, engaging in the practice of Motivational Interviewing and using Brief Action Planning (BAP) o er signi cant value in applying many of the behaviour change theories discussed in this section. Motivational Interviewing (MI) Motivational Interviewing (MI) is a way of working with clients to assist them in accessing their motivation and con dence to change behaviour (Miller & Rollnick, 2013). While links have been drawn between MI and theories such as the TTM, MI was not explicitly derived from any one health behaviour theory (Miller & Rollnick, 2013; Miller & Rollnick, 2009). MI is founded on the premise that lasting change is more likely when clients discover their own reasons to change. As such, it aligns well with current lifestyle change research that identi es client-centered counselling strategies as being more e ective than practitioner- centered approaches. It also recognizes that individuals start out at di erent levels of readiness to change their behaviour. Some may have thought about change, but have not yet resolved their indecision and taken steps toward change. Others may be actively trying to change their behaviour and may have had several unsuccessful attempts to change already. Rather than telling clients what to do and how to do it, a quali ed exercise professional can use MI as a guide to facilitate the client’s own examination of the positive and negative aspects of change. Clients are recognized as the experts on their own lives (competence) and are actively empowered to identify, evaluate, and choose (autonomy) the changes that will work for them. A clients’ autonomy is actively cultivated by: drawing out and acknowledging client perspectives and values; linking change to the client’s broader goals and values; and by o ering options for the client to choose from. There are four elements that re ect the “spirit of MI” and are essential to its practice (Miller & Rollnick, 2013). As a quali ed exercise professional you can assess whether or not you support these four elements that capture the spirit of MI: Partnership: Do you recognize that your client knows themselves the best? Does the time that you spend together with your client re ect the client’s agenda or your own agenda? Is it a team e ort? Acceptance: Do you as the quali ed exercise professional see that the client has worth? Do you express empathy? Do you a rm the client’s own strengths? Do you support the client in choosing what is best for themselves even if you know better? Compassion: Do you put the needs and wellbeing of your client rst? Evocation: Do you focus on what your client is missing or lacking or do you align with the “MI perspective?; that there is a deep well of wisdom and experience within your client from which you can draw. Much of what is needed is already there, and it’s a matter of drawing it out, calling it forth" (Miller & Rollnick, 2013). Motivational Interviewing Basics Miller and Rollnick (2013) are clear that MI re ects a “style of being with people” rather than a “technique”. This style and the skills that are utilized within MI take time to master. Key features of MI include helping clients:  Discover their own interest in considering and/or making a change in their life (e. g., diet, exercise). Express in their own words their desire for change (i. e., change-talk). Examine their ambivalence about change as a means to elicit and strengthen their change talk. Enhance their con dence in taking action and noticing that even small, incremental changes are important. Strengthen their commitment to change. Plan for and begin the process of change. Quali ed exercise professionals who wish to master the skills and techniques of MI should seeking out additional professional development and training opportunities. To engage in MI, the quali ed exercise professional will employ such skills as open-ended questioning, active listening, eliciting ‘change talk’ from the client, e ectively managing a client’s resistance to change, and guiding the client through an exploration of the gap between where they are and where they want to be (Miller & Rollnick, 2013; Miller et al., 2009; Moore, 2007). Tips for Motivational Interviewers Motivational Interviewing is about helping clients discover their interest in considering and making a change in their lives such as becoming more active. Quali ed exercise professionals can ask themselves the following questions to build self-awareness about their own attitudes, thoughts, and communication style and keep their attention focused on the client being served. Do I listen more than I talk? (Or am I talking more than I listen?) Do I keep myself sensitive and open to this client’s issues, whatever they may be? (Or am I talking about what I think the problem is?) Do I invite this client to talk about and explore their own ideas for change? (Or am I jumping to conclusions and  ideas for change? (Or am I jumping to conclusions and possible solutions?) Do I encourage this client to talk about their reasons for not changing? (Or am I forcing them to talk only about change?) Do I ask permission to give my feedback? (Or am I presuming that my ideas are what they really need to hear?) Do I reassure this client that ambivalence to change is normal? (Or am I telling them to take action and push ahead for a solution?) Do I help this client identify successes and challenges from their past and relate them to present change e orts? (Or am I encouraging them to ignore old stories?) Do I seek to understand this client? (Or am I spending a lot of time trying to convince them to understand me and my ideas?) Do I summarize for this client what I am hearing? (Or am I just summarizing what I think?) Do I value this client’s opinion more than my own? (Or am I giving more value to my viewpoint?) Do I remind myself that this client is capable of making their own choices? (Or am I assuming that they are not capable of making good choices?) Source: Adapted from Kruszynski, et al., MI Reminder Card (Am I Doing This Right?). Center for Evidence-Based Practices, Case Western Reserve University, 2012. Open-Ended Questioning To help a client nd the power to change from within, the interviewer must draw out the client’s story, motivation for change, and prior history in attempting the change. A useful approach is expressing curiosity about the client’s experience and views using open-ended questions that cannot simply be answered with ‘yes’ or ‘no’. For example: What is it that brings you here today?  What is working or not working in your life right now? What would you like to be di erent? If in a year, you were living in a way that felt good to you, what would feel di erent? What’s the smallest step you could take to start moving in that direction? Active Listening Active listening is essential to developing the insight required to facilitate clients’ exploration of motivation and options for change. The tools of active listening (i. e., a rmations, paraphrasing, summarizing, and re ection on meaning and feelings) can be used to accurately demonstrate understanding of the information the client has shared. For example, “If I heard you correctly, you are saying…” or “It sounds like you feel…”. Re ection is particularly important in con rming the interviewer’s non-judgmental understanding of the client’s perspectives and encouraging deeper revelations. See Table 3.2 for more examples of the use of re ection in MI. TABLE 3.2 Type of Re ection Tactics Used in Motivational Interviewing DESCRIPTION (What the MI Practitioner says in TYPE Response to the Client) Content Used to elicit the basic facts in the re ections client’s story and generally entail paraphrasing what the client has said. “So, you are here because your health care provider wants you to lose weight and you’d rather exercise than go on a diet.” DESCRIPTION (What the MI Practitioner says in TYPE Feeling/meaning Response to the Often take Client) the form of “You are feeling re ections embarrassed about your weight”. Meaning re ections may also include a statement about why the person feels a certain way or how a feeling or action may be related to other important aspects of the person’s life. Acknowledging emotional intensity is a powerful way to quickly build rapport and encourage the client to fully disclose their thoughts and feelings. Ampli ed These are a way of exaggerating the negative bene ts (or minimizing the harm) re ections associated with the undesirable behaviour. It may take the form of, “so you see no bene t in changing your physical activity levels” or “being sedentary is all positive for you.” Such an approach can help draw out and exhaust the client’s negativity. In response, clients will often then reverse their course, and start to argue for change. It is particularly useful when clients appear stuck in a “yes, but” mindset. Double-sided These can be used to acknowledge that re ections the practitioner heard the client’s reasons both for and against change. They typically take the form of, “on the one hand, you would like to get more active, but on the other hand that might mean watching less television” or “you are torn about spending more time being DESCRIPTION active.” (What the MI Practitioner says in TYPE Response to the Client)  Action Often used after the client has moved re ections beyond ambivalence into action planning, these re ect possible solutions to the client’s barriers or a potential course of action. They usually re ect a potential concrete step that the client has directly or obliquely mentioned (i.e., they should not slide into the category of unsolicited advice). Action re ections can include multiple choices to support the client’s autonomy. For example “Based on what you said there seem to be several possible options including walking after dinner each night or cycling to and from work.” “Sounds like, in order to move forward, you might want to gure out ways to t physical activity time into your busy schedule.” “So you might consider cycling to work or walking during your lunch hour.” “Sounds like walking after dinner each night may be a possibility.” “Sounds like in order to move forward, you may have to think about how you spend time in the evenings di erently.” Reference: Adapted from Resnicow et al., International Journal of Behavioural Nutrition and Physical Activity 2012, 9:19. Eliciting ‘Change Talk’ Ambivalence – or having mixed feelings about something – is often present in people who contemplate health-related behaviour change. It refers to a person feeling two ways about a potential change. For example, a client may want to be more active, but says he or she is too tired by the end of the workday to do so. On the one hand the client has good reasons to make the change, but there are other equally compelling reasons to not change. He or she is ambivalent about getting more active, even though your client may know of the bene ts. To help clients work through their ambivalence, a quali ed exercise professional can use MI strategies to elicit change talk, which refers to the client’s discussion of their desire (“I want to change”), ability (“I can change”), and need to change (“I must change in order to…”). The e ective motivational interviewer seeks to encourage and reinforce change talk by asking the client to consider how their life may unfold with or without the change. Readiness rulers can be helpful in this regard. For example: “On a scale of 1 to 10, how important is this change to you?” “Assuming you want to change, how con dent are you that you can make this change?” “Why are you an 8 and not a 3?” “What would it take to get you to a higher number?” As clients resolve their ambivalence, their change talk will usually start to shift to speaking in terms of the commitment to change (“I will make this happen”) and they will be ready to move to a more pragmatic examination of how to implement the change (Miller & Rollnick, 2013). Managing ‘Sustained Talk’ Resistance to change will sometimes be evident in a client’s sustained talk. For example, a client may articulate reasons for sticking with current behaviour patterns as part of the process of resolving ambivalence. Instead of o ering counter arguments, the skilled motivational interviewer allows clients to express their reasons for not undertaking change without feeling pressured to change or worrying about being judged for not wanting to change. This approach allows the motivational interviewer to strategically de-escalate and refocus the discussion so progress can be made. The motivational interviewer can accomplish this by inviting the client to consider other perspectives. When this is not su cient to move the client forward, a form of re ection called ampli ed negative re ection (i. e., exaggerating the bene ts or minimizing the harm; “So at the moment, your weight and being out-of-shape are not of concern to you?”) may help get the client to re-evaluate. Developing Discrepancy Motivational interviewing is essentially about helping clients explore the gap between where they currently are and where they want to be in the future. The greater the gap, the harder it is for the client to justify the current behaviour, the more attractive change becomes, and the less ambivalence the client will feel about the change. By linking the discrepancy to the client’s personal goals and values, the motivational interviewer helps the client re ect on the advantages and disadvantages of change facilitate their move toward change. Helping a client perceive discrepancy requires carefully chosen re ections and/or open-ended questions to underscore incongruities. It is important to separate the behaviour from the person and to carefully listen to the client’s statements about personal values and concerns about their current behaviour, and then re ect these back to the client as a means of heightening and acknowledging the discrepancy. Once a client begins to understand how the (potential) consequences of current behaviour con ict with signi cant personal values, amplify and focus on this discordance until the client can articulate consistent concern and commitment to change. Self-Ef cacy in Motivational Interviewing Building self-e cacy is core to Motivational Interviewing. The quali ed exercise professional should strive to bolster the clients’ self-e cacy so that they have the capacity to make regular physical activity part of their lives. At the outset, the QEP may simply congratulate clients for taking the rst step in seeking assistance. If a client reveals discouragement about past attempts to change that were unsuccessful, the QEP might reinforce self-e cacy by complimenting the client’s perseverance in trying again and asking the client to re ect on what they learned from the past attempt. This can also get the client thinking about the barriers they faced and how they might manage those barriers (i.e., forming, coping, planning). Moving from Why to How A recent adaptation of the MI model was introduced to address a challenge in determining when and how to transition from building motivation and commitment to planning a course of action. The model conceives MI in three phases: 1. Exploring (i. e., drawing out the client’s story, building rapport, obtaining a behavioural history, and identifying what behaviours are to be discussed), 2. Guiding (i. e., steering the conversation toward the possibility of change by asking the client to consider life with and without change to help the client see the discrepancy between current actions and broader life goals and values), and 3. Choosing (i. e., once a commitment to making a change occurs, the conversation moves to a more pragmatic discussion of HOW to put the desired change into action) (Resnicow et al., 2012). Brief Action Planning Another tool available to help the quali ed exercise professional is Brief Action Planning (BAP). Gutnick and colleagues (2014) de ne BAP as “a highly structured, stepped-care, self-management support technique… Composed of a series of 3 questions and 5 skills…”. Key features of BAP relevant to quali ed exercise professionals include (Gutnick et al., 2014): Delivery: Clinicians or other allied health professionals such as quali ed exercise professionals can be trained to use and deliver BAP. Time: BAP with a trained professional may take as little as 5 minutes, but it is also easily accomplished within a 20-30  minute consultation session. Use: BAP is exible in terms of when it can be used with clients. BAP may be used during an initial visit and/or during follow-up visits. BAP may be used once or more than once with a client. How was BAP developed?: BAP is based upon literature identifying the need to support the development of client self-e cacy as well as creation of appropriate action plans. Further, BAP is also derived from MI, with a particular emphasis on the “spirit of MI”. Evidence supporting BAP: BAP has been recently used in several studies to promote physical activity among individuals with osteoarthritis (Li et al., 2017), spinal cord injury (Gainforth et al., 2014). BAP has also been used in a primary care intervention focused on preventing chronic disease (e.g., Sopcak et al., 2016; 2017) which is also being examined in a public health setting (Paszat et al., 2017). How do you do BAP?: Gutnick et al.’s (2014) paper is a starting point for any quali ed exercise professional looking to better understand BAP. Training opportunities as well as freely available online resources are available from the Centre for Collaboration, Motivation, and Innovation: https://centrecmi.ca The Brief Action Planning Flowchart and the Brief Action Planning Guide shows practitioners the key questions and skills associated with BAP. In keeping with the tenets of MI, client autonomy and awareness of readiness to change are upheld, client con dence is explored, and any information provided is consistent with MI by way of asking permission. According to Gutnick et al. (2014), and as shown in Figure 3.5, BAP begins with a question that may be broad (i.e., “Is there anything you would like to do for your health in the next week or two?”) or may accurately re ect the client (i.e., “We’ve been talking about diabetes, is there anything you would like to do for that or anything else in the next week or two?”. The ow of conversation then depends upon the client response. For clients who are not yet ready or willing to do anything in the next week or two, the QEP should respect the client’s autonomy. For clients who are unsure, the next step in the BAP is to ask permission (i.e., be MI- consistent) to discuss a “behavioral menu” of options. Once the client is able to identify an option from the menu or if a client responds that they “have an idea” after the opening question, next steps are to work with the client to devise an action plan that is consistent with SMART goals and to elicit commitment by asking the client to “tell back” the speci cs of the plan (Gutnick et al., 2014). FIGURE 3.5 Brief Action Planning Flow Chart Developed by Steven Cole, Damara Gutnick, Connie Davis, Kathy Reims Brief Action Planning Flow Chart Available at: https://centrecmi.ca/wp- content/uploads/2017/08/BAP_ ow_Chart_2016-08-08.pdf Brief Action Planning Guide Available at: https://centrecmi.ca/wp- content/uploads/2017/08/BAP_Guide_2016-08-08.pdf Reprinted with permission from the Centre for Collaboration, Motivation, and Innovation. The second question probes client’s self-e cacy for using the con dence ruler (similar to the readiness ruler discussed in the previous section of MI). Essentially, the quali ed exercise professional asks the client to rate their con dence to carry out the action plan on a scale from 1-10. For clients who respond to having lower con dence (in BAP this is less than a 7 out of 10), the quali ed exercise professional and client can together brainstorm and explore ways in which client self-e cacy can be increased. The third and nal question can see the quali ed exercise professional ask the client: “Would you like to set a speci c time to check in about your plan to see how things have been going?” (Gutnick et al., 2014). The BAP authors suggest this is a way to support client accountability. A follow-up should also take place. Conclusion The CSEP-PATH® client-centered process outlined in this Resource Manual o ers quali ed exercise professionals speci c advice on how to apply the key behaviour change theories, motivational interviewing skills, and brief action planning skills in a systematic way. The CSEP-PATH® Section of this Resource Manual describes the process of building rapport and gathering information from clients, helping clients identify obstacles and ways to work around them, and setting goals and action plans for achieving them. 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