Aims: To have increased awareness of the factors that affect an individuals readiness to change. To explore the theoretical models that underpin change behaviour To develop awareness of skills and strategies to support individuals and their families.

1. Practical Hints and Tips
for Assessing
Readiness to Change
Dr Bronwen Bonfield
Principal Clinical Psychologist
Community Neurological Rehabilitation Service
Buckinghamshire Healthcare Trust
November 2016

2. Aims of the Session
 To have increased awareness of the
factors that affect an individuals
readiness to change.
 To explore the theoretical models that
underpin change behaviour
 To develop awareness of skills and
strategies to support individuals and
their families.

3. CNRS In-Service
Background to experience in this area:
 Multidisciplinary team inservice topic over the
last year.
 Explored the main question regarding
‘Why don’t some people progress as we would expect
(achieve functional change and learn to self-manage their
condition), when they present with sufficient levels of physical
and cognitive skills to do so?’
Led the team to develop three clinical questions
 What affects a persons motivation and readiness to change?
 What skills as clinicians do we need to identify and draw out a
client’s readiness to change within neurological rehabilitation?
 How can we provide the right therapy, to the right patients at the
right time?

4. Rehabilitation in MS
 Much of neurological rehabilitation is
interested in helping people to manage
functional change over the duration of their
condition (Therapists in MS delivering the
long term solutions 2006).
 A growing body of evidence emphasises the
importance of effective self management of
long-term conditions. It is recognised that
those people who successfully self-manage
their condition experience better health
outcome (Hibbard J & Gilburt 2014)

5. Self-Management - The importance of
well-being
Living a meaningful life that is striving towards what we value
promotes well-being.
Each individual will have their own set of values which creates
meaning.
When our lives are “in balance” we have capacity to deal with
life’s events – whether positive or challenging.
We can enjoy the positives and manage the challenges.
Our lives are like jigsaws – when they fit together to make a
whole – again life seems manageable.
However, when we experience stressful life events, changes to
our health – our life jigsaw is thrown up in the air, breaks up and
lands disjointed.
It takes time, support and advice to get the jigsaw back together
and sometimes it does not fit quite as it did before.
Adjusting to this and accepting this new position, physically,
emotionally, will enable us to regain balance in our lives.

6. The Biopsychosocial Model
Biological/
Physical Impact
Social Impact
Psychological
Impact
We need to understand the factors that interact and inform our well-being

7. Challenges in Rehabilitation
‘Why don’t some people progress as we would expect
(achieve functional change and learn to self-manage their
condition), when they present with sufficient levels of
physical and cognitive skills to do so?’

8. How our clients present
When I get
better…….
When I get
back to
normal
Work within
the session –
no carry over
Family report
frustration –
no action
Yes….but
Family want
more
rehabilitation

9. The Therapist Response
They have
potential –
I must fix
this
Why aren’t
they
moving
forward?
What can I
do next?
Frustration
Heartsink
Doubt
Uncertainty
Burn out

10. Effects of the cycle
 Patients remain in therapy for longer periods of time
 Expressed higher levels of dissatisfaction when discharged
 Re-referred quickly either by external referral or self-referral
 Therapist dissatisfaction
 Challenges within the therapeutic relationship

11. How do we understand this
behaviour?
There are multiple models that can
inform us: social cognition model,
health belief model and stages of
change model
We will focus on stages of change
model

12. Precontemplation
Contemplation
ActionMaintenance
Relapse
Individual leaves
Treatment
Stages of Change Model

13. Precontemplation
Client not intending to change
or not aware of the need to do
so…
We identify these clients as
RED Flag

14. Contemplation
The individual has some
awareness that they have a
problem and they are thinking
about changing.
We identify these clients as
YELLOW flag

15. Action
Actively taking part in
behavioural change (e.g. active
participant in rehab programme)
We identify these clients as
GREEN Flag
In our service we have identified
that 60% were green and 40%
amber/red

16. Maintenance & Relapse
 Maintenance
Making good progress (e.g. taking responsibility for self-
management of condition)
- this would represent clients who have achieved goals – we
may review and then discharge
 Relapse
Client reverts back to earlier stage of cycle of change

17. Factors that are barriers to
change Lack of awareness of rehabilitation process.
 Lack of self awareness.
 Poor insight.
 Cognitive/emotional deficits.
 Denial
 Negative perception of self.
 Unhelpful belief system/rules for living.
 Lack of MDT approach.
 Poor acceptance.
 Inability to reform values.
 Inability to remodel self.
 Feeling powerless.
 Over protection by others.

18. Hints & Tips
Within any therapeutic relationships key skills
are:
- Remembering it is a partnership; working in
collaboration
- Empathy and compassion
- Acknowledging the individuals strengths and
efforts
- Open questions
- Reflective listening
- These are core skills in Motivational
Interviewing - strengthening an individual’s
motivation and commitment to change.

19. Hints and Tips cont…
Precontemplation
from a service perspective these are clients who need preparation before
entering a rehabilitation programme.
- Psychological Group programmes re: acceptance to their
condition
Other strategies if this is not available:
- Listen and summarise the clients issues
- Raise awareness of the benefits of the service available to
them
- Raise awareness of the disadvantages of staying as they are
- Preserve the therapeutic relationship to enable access to the
service at a later date.
- Information – leaflet with contact details on. Check the
meaning of the information to the client.

20. Hints and tips cont…
Contemplation
 Support the client’s problem-solving and
decision making by:
- discussing advantages and disadvantages of
changing in relation to client (rather than in
general)
 help client identify where they would like to
focus attention first
 acknowledge that behaviour change is not
easy – provide opportunities for person to
voice their reservations about taking action
 offer further support e.g. via follow-up
appointment

21. Hints and Tips cont….
 Agenda Setting
◦ Can be a very useful way of identifying
current priorities

22. Hints and Tips cont…
Confidence Scales
Using a confidence scale can indicate how the client actually feels
about completing a task
For the task to be realistic the rating should be around 6 – 7
0 1 2 3 4 5 6 7 8 9 10
If the client rates the task 8 – 9 – it could reflect something they
are already achieving or something that will not move them
forward.
If the client rates the task 5 and below it enables further
exploration

23. Hints and tips cont…
Action
 Helping client identify strategies that
work for him/her
 Acknowledge success to bolster
confidence and self-esteem
Provide strategies to help reduce stress
(e.g. relaxation techniques)
 Set further achievable goals; consider
client keeping diary to monitor behaviour
so clinician can help identify what may
be preventing progress

24. Hints and tips cont….
Relapse
 Reinforce to client that this is a
normal
experience and does not signify
failure
 Discuss triggers; identify strategies
that
have worked so far
 Help identify where client needs to
jump

25. Hints and tips cont….
Maintenance
Reinforcing the strategies that have
helped the client
Start bringing in other sources of
community support
Agreeing follow-up appointment or
phone call; assurance that support is
available if the client needs it

26. Factors that promote behavioural
change
 Goals
 Action Phase
 Use of Motivational Interviewing.
 Feeling empowered.
 Peer support.
 +ve patient/therapist relationship
 Management of expectations.
 +ve feedback on performance.
 +ve outcome facilitating on-going change.
 Follow-up.
 Acceptance and re-formulation of values.
 Ability to remodel self.

27. Team Considerations
 Current knowledge
 Skills and effectiveness in change
behaviours
 Evaluate current practices
 Identify training needs

28. Referring On
If the barrier to change is linked with
depression or anxiety then referring to a
psychological service will be helpful.

29. Thank you for listening
Any Questions?

30. Social Cognition Model
“The beliefs that individuals hold about the
outcomes of their actions are key
determinants of their health-impairing or
health-protective behaviours”
Cognitive representations of health
threat
Emotional response to health threat

31. Health Belief Model
 “The Health Belief Model assumes
that for a person to engage in a
recommended health-protective
behaviour, they must perceive the
benefits to outweigh the costs”