Interpersonal Skills of the Helper - Theories and Models of Health Behaviour Change

Session Aims

• Explore and recognize different types of motivation and their impact on treatment outcomes.
• Define extrinsic and intrinsic motivation.
• Further develop interpersonal skills, self-reflection, and cultural competence.
• Increase awareness of the importance of self-determination theory in health practice.
• Discuss the purpose and application of the Transtheoretical Model of Change.

What is Motivation?

• Motivation: What drives us to do the things we do?
• Why are we more motivated to do some things than others?

What is Self Determination?

• Self-determination (SD) is each person’s ability to make choices and manage their own lives.
• SD plays an important role in well-being and psychological health.
• SD can be applied to many areas including education, work, parenting, exercise, and health.
• SD has a significant impact on motivation.

What is Self Determination Theory?

• Self-determination theory grew out of the work of psychologists Edward Deci and Richard Ryan.
• They first introduced their ideas in Self-Determination and Intrinsic Motivation in Human Behavior (1985).
• They developed a theory of motivation which suggested that people tend to be driven by a need to grow and gain fulfillment.

Self Determination Theory - Key Assumptions

1. The need for growth drives behavior – people are growth oriented.
   • Challenges are opportunities to gain mastery and to experience new things and this is essential for wellbeing and a sense of self.
2. Intrinsic motivation is important.
   • Even though people may be motivated by external rewards such as money, duty or acclaim, a person’s internal sources of motivation help create a sense of autonomy which is vital to wellbeing.

Self Determination Theory - Ryan and Deci Quote

• “Perhaps no single phenomenon reflects the positive potential of human nature as much as intrinsic motivation, the inherent tendency to seek out novelty and challenges, to extend and exercise one's capacities, to explore, and to learn.” (Ryan and Deci, 2000, p. 70)

Self Determination Theory and C.A.R

• C.A.R. stands for Competence, Autonomy, and Relatedness.

Self Determination Theory: C.A.R.

• According to SD theory, the following are essential for psychological growth and wellbeing:
  • Competence: People need to gain mastery of tasks and learn different skills.
    • This enables them to take actions to help achieve their goals and to feel effective.
  • Autonomy: People need to feel in control of their own behaviors and goals.
  • Relatedness: People need to experience a sense of connection and belonging to others.
    • To feel understood and cared for.
• Support and satisfaction of these needs provides the basis for the psychological energy that motivates the initiation and long term maintenance of health behaviours” (Ryan et al., 2008; Silva et al., 2011).

Intrinsic vs Extrinsic motivation

• Ryan and Deci (2000) identified that there is a continuum from amotivation to extrinsic motivation to intrinsic motivation with two main categories of motivations:
  1. Intrinsic: Roots in basic human needs of autonomy, competence and relatedness.
     • Individual’s internal reward drives a behaviour: personal values, interests, pleasure.
     • Example: I study Complementary Medicine because I find it interesting.
  2. Extrinsic: External rewards or potential punishments are driving a behaviour.
     • Example: I study Complementary Medicine because my parents want me to.

Motivation - Definitions and Examples

• Intrinsic Motivation: Motivation due to the inherent enjoyment derived from the behaviour itself. A facet of autonomous self-regulation.
  • Example: “I exercise because it is fun and pleasurable.”
• Integrated regulation: Motivation to engage in behaviours which are in congruence with other central personal goals and values. A facet of autonomous self-regulation.
  • Example: “I exercise because I consider exercise a fundamental part of who I am.”
• Identified regulation: Motivation reflecting the personal value of the behaviour’s outcomes. A facet of autonomous self-regulation.
  • Example: “I exercise because I value the benefits of exercising.”
• Introjected regulation: Motivation reflecting internal pressures such as contingent self-worth, guilt, shame, and need for external approval. A facet of controlled regulation.
  • Example: “I exercise because I will feel guilty when I don’t.”
• External regulation: Motivation to comply with external pressures or rewards. A type of controlled regulation.
  • Example: “I exercise because my physician says I should.”
• Amotivation: The state of lacking intention to act.
  • Example: “I can’t see why I should bother exercising.”

Written Reflection - Intrinsic versus Extrinsic Motivation

1. Write down activities in your life which you do regularly and with ease. Reflect on how competency, autonomy and relatedness needs are met in these activities. Consider whether these activities are extrinsically or intrinsically motivated or both?
2. Write down activities in your life which you do reluctantly. Reflect on how competency, autonomy and relatedness needs are met in these activities. Consider whether these activities are extrinsically or intrinsically motivated or both?
3. How is this important for your work with clients?

TRANSTHEORETICAL MODEL OF CHANGE

• Reflect on two different personal changes you feel:
  1. A change you have made or attempted in the past.
  2. A change you have considered but have not yet made.

The Trans-Theoretical Model of behaviour change

• A cross-theoretical model of behaviour change proposed by Prochaska & DiClemente in 1983.
• It is applied i.e. in counselling interventions, behavioural sciences, prevention and policy-making settings, etc.
• Hence, the name Trans-theoretical.
• It suggested that a critical component of behavioural change is readiness for change.
• The Trans-theoretical model of behaviour change is a biopsychosocial approach designed to understand and facilitate a process of intentional behaviour change.

The Trans-Theoretical Model of behaviour change

• Referred to as the Trans-Theoretical or stages of change model, it:
  • Emphasises the individual’s decision-making capacity and intentionality.
  • Suggests that people do not change quickly, and that change takes place over a period of time.
  • States that particular behaviours, especially addictive type behaviours, undergo a cyclical process.

Stages of Change

• PRECONTEMPLATION: The client has not considered changing at all and is fully engaged in the behaviour – unmotivated and no intention to change.
• CONTEMPLATION: The client is considering change and “thinking about it” – problem is recognised often as a consequence of a trigger event.
• DETERMINATION/PREPARATION: The client has made the decision to change and starts making plans to change – pre change steps.
• ACTION/TRYING: The client begins to change by engaging actively in changing- ‘willpower’ stage.
• MAINTENANCE: The client has achieved the change and is maintaining it- consolidation stage with strategies to cope with relapse in place and working.
• RELAPSE: Can occur at any point in the cycle and a client may fall back to any of the previous stages.
• TERMINATION/ADVOCACY/TRANSCENDENCE: New stage added later by researchers to include the awareness that old unhealthy behaviours are no longer conceptualized as appropriate.

Trans-theoretical Model: Processes

• As individuals progress through the stages of change they undergo a range of emotional, cognitive and evaluative processes such as:
  • Consciousness Raising: Increased awareness around specific behaviour.
    • Example: I recall information people had given me on how to stop smoking.
  • Self re-evaluation: Client attempts to re-image oneself.
    • Example: My dependency on cigarettes makes me feel disappointed in myself.
  • Environmental re-evaluation: Awareness of how personal unhealthy behaviour affects others.
    • Example: I consider the view that smoking can be harmful to the environment.
  • Social Liberation: Need to identify socio-cultural opportunities supportive of the new behaviour.
    • Example: I find society changing in ways that make it easier for the nonsmoker.
  • Self-liberation: The belief that the new behaviour is possible and then the commitment to it.
  • Helping Relationships: Identify and seek caring, trusting and accepting relationships that encourage the desired change.
    • Example: I have someone who listens when I need to talk about my smoking.
  • Counter-Conditioning: Learning desired behaviours that substitute for undesired ones.
    • Example: I find that doing other things with my hands is a good substitute for smoking.
  • Contingency Management: Reward positive behaviour and reduce the rewards that come from negative behaviour.
    • Example: I reward myself when I don’t smoke.
  • Stimulus Control: Change your environment to have cues that support and encourage desired behaviour and remove those that encourage the undesired behaviour.
    • Example: I remove things from my home that remind me of smoking.

Limitations of the Transtheoretical Model

• Does not take into account the socio-cultural differences and context of the client e.g. an orthodox catholic cannot use contraception.
• No real identifiable criteria around the various stages.
• No real sense of the amount of time each individual spends at each stage.
• Assumes that individuals make clear cut decisions and plans within their decision making process, possibly in a linear way, which is often not the case.

Stages of Change - Practitioner Techniques

• Pre-Contemplation
  • Characteristics: Not currently considering change: "Ignorance is bliss"
  • Practitioner Techniques:
    • Validate lack of readiness.
    • Clarify: decision is theirs.
    • Encourage re-evaluation of current behaviour.
    • Encourage self-exploration, not action.
    • Explain and personalize the risk.
• Contemplation
  • Characteristics: Ambivalent about change: "Sitting on the fence" Not considering change within the next month.
  • Practitioner Techniques:
    • Validate lack of readiness.
    • Clarify: decision is theirs.
    • Encourage evaluation of pros and cons of behaviour change.
    • Identify and promote new, positive outcome expectations.
• Preparation
  • Characteristics: Some experience with change and are trying to change: "Testing the waters" Planning to act within 1 month.
  • Practitioner Techniques:
    • Identify and assist in problem solving re: obstacles.
    • Help client identify social support.
    • Verify that client has underlying skills for behaviour change.
    • Encourage small initial steps.
• Action
  • Characteristics: Practicing new behaviour for 3-6 months.
  • Practitioner Techniques:
    • Focus on restructuring cues and social support.
    • Bolster self-efficacy for dealing with obstacles.
    • Combat feelings of loss and reiterate long-term benefits.
• Maintenance
  • Characteristics: Continued commitment to sustaining new behaviour Post-6 months to 5 years.
  • Practitioner Techniques:
    • Plan for follow-up support.
    • Reinforce internal rewards.
    • Discuss coping with relapse.
• Relapse
  • Characteristics: Resumption of old behaviours: "Fall from grace"
  • Practitioner Techniques:
    • Evaluate trigger for relapse.
    • Reassess motivation and barriers.
    • Plan stronger coping strategies.

Reflection Questions

1. What is self determination and why is it important?
2. What is the difference between extrinsic and intrinsic motivation?
3. What are the stages in the Transtheoretical Model of Change?
4. In your opinion, what was the most useful idea discussed in today’s class?
5. During today’s class, what idea(s) struck you as things you could or should put into practice?
6. What do you think was the most important point or central concept communicated during today’s presentation?