Readiness to Change

The only reason people change their behavior is because they want to do so. Readiness to change is tied to a person’s motivation or what is referred to as motivational readiness. A central element in increasing motivation and eventual behavioral change is to take into account the person’s readiness to change. Behavior change occurs in stages over time (Prochaska et al, 1992; Center for Substance Abuse Treatment, 2008).

The first stage of change is precontemplation. In this stage people do not think that they have a problem; thus they are not likely to seek help or participate in treatment. In working with these patients the goal is to listen to the patient and create a climate in which the patient may consider, explore, or see value in the benefits of changing.

The second stage of change is contemplation. This is characterized by the notion of “yes, but.” Often patients recognize that a change is needed, but they are unsure and indecisive about whether it is worth the time, effort, and energy to achieve it. They are ambivalent about what they might have to give up if they make a change. In working with these patients, the goal is to create a supportive environment in which the patient can consider changing without feeling pressured to do so. If patients are pushed to change in this phase, they are likely to actively resist.

The third stage of change is preparation. At this time the patient has made a decision to change and is assessing how that decision feels. Patients can be helped to select realistic treatment goals and different ways to reach those goals. They need to be actively involved in designing their own strategies for change.

The fourth stage of change is action. Patients now have a firm commitment to change and have identified a plan for the future. They should be offered emotional support and help in evaluating and modifying their plan of action to be successful.

The fifth stage of change is maintenance. Change continues, and focus is placed on what the patient needs to do to maintain or consolidate gains. Anticipating potential threats for relapse and developing prevention plans are essential. Any relapses should be seen as part of the change process and not as failure.

The sixth and final stage is termination. It is based on the notion that one will not engage in the old behavior under any circumstances. As such, it may be more of an ideal than an achievable stage. Most people stay in the stage of maintenance where they are aware of possible threats to their desired change and monitor what they need to do to keep the change in place.

Patients are more likely to engage in behavior change when their provider assesses their readiness for change and tailors their interventions accordingly. Table 27-1 summarizes these stages of change. Figure 27-1 shows the stages of change model applied to substance use disorders.

Motivational Interviewing

Motivation to change comes from within the individual. Without the desire or motivation to change, a person will not change one’s behavior. Motivational interviewing is a patient-centered, directive counseling method for enhancing a person’s internal motivation to change by identifying, exploring, and resolving ambivalence (Rollnick et al, 2008).

Everyone has ambivalence about changing, and there are always advantages and disadvantages to making a change. A person is motivated to change when one’s values and goals conflict with one’s current behavior and when the benefits of change outweigh the benefits of staying the same.

Ambivalence→Discrepancy→Behavior Change

Most people are aware of their unhealthy behaviors. Clinicians seeing these behaviors point them out and advise change; however, too often patients’ natural responses are to defend themselves and resist any suggestion of change.

The four key elements of motivational interviewing are as follows:

Motivational Interventions

A number of interventions can be used to enhance a patient’s motivation to change. The use of open-ended questions can help to identify the patient’s agenda. Affirming, hopeful, and reinforcing statements can emphasize that change is possible. One can also focus on the disadvantages of the way things are and the advantages of change.

The nurse can ask simple questions about how important the change is to the patient and how confident the patient is about making the change based on a scale of 1 to 10 (10 being the highest) to help to gain a sense of where the patient is in the stages of change. In working with patients, nurses must be sensitive to issues of mutuality, which means not prescribing solutions to the patient as the passive recipient of care. It also means not labeling problems or placing blame, both of which are likely to decrease the motivation to change.

Critical aspects of effective motivational interventions include the FRAMES approach and decisional balance exercises. FRAMES stands for the following basic elements of motivational counseling:

Decisional balance exercises are specific ways that the clinician can assist the patient to explore the pros and cons of old and new behaviors for the purpose of tipping the scales toward a decision for positive change. The items are identified by the patient with gentle help from the clinician and then written in a grid. This is shown in Figure 27-2 for a patient who has an alcohol use problem. The four blocks of the grid add a new twist to the traditional two-column “pros and cons” list.

One advantage of the four-block grid is recognition that there are positive elements about the old behavior that must be acknowledged. For example, if drinking helps the patient relax, part of recovery may include finding other ways to relax without alcohol. Even more important than the number of items in each block is the weight of each item. For example, the negative impact on the family may more than outweigh the social pleasures of drinking.

The clinician then summarizes the list of concerns and presents them to the patient in a way that expresses empathy, develops discrepancy, and weighs the balance toward change. The objective is to meet the patients where they are in their thinking, walk with them through the process and help them commit to making needed changes in their lives.

The nurse should be proactive and summarize the patient’s perception of the problem, areas of ambivalence, and desire to change. Asking the key question, “What is the next step?” is critical. Setting goals, listing all possible options, supporting the patient’s decision to engage in a plan of action, and reinforcing success in achieving it are essential nursing interventions.