Behavior Therapy Moving Your Clients From Talk to Action

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Behavior TherapyMoving Your Clients From Talk
to Action

• Exercise, Diet, and Weight Management
• Instructor Samantha Rubin, MS, RD, CDE

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Introduction

• Behavior Therapy- basic learning principles that
  can help you overcome barriers to changing eating
  and exercise habits
• Treatment record not great
• Due to an inappropriate treatment emphasis?
• Focus on body weight rather than factors that
  might influence body weight
• treatment focuses on outcome versus means to the
  outcome

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New Paradigm focuses on healthy living

• Robinson et. Al
• Rather than defining treatment and success in
  terms of weight loss, focus on health related
  behaviors
• Weight influenced by a variety of factors
• modifiable- quantity/quality of food, FIT of
  physical activity, emotional state
• non-modifiable- genetic factors
• Healthy lifestyle paradigm focuses on the
  modifiable factors
• Influence on weight
• genetics 25-40
• environment- remaining

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Concepts that guide weight management

• Authority centered intervention
• MD writes diet orders
• RD provides calorie controlled diets
• client passive participant
• Client centered intervention
• empower the individual to be responsible for
  daily management
• client active participant
• encourage client to identify problem situations
  and assist in developing solutions

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Build a Therapeutic PartnershipSet the Stage

• Key ingredients Rapport, Trust, and Mutual
  Respect
• Elicit clients experiences using open-ended
  questions
• allow client to tell his/her story in his/her own
  words
• Reflective listening
• lets the client know you are trying to understand
  his/her situations and challenges
• Empathy and non-judgmental attitude
• communicates your acceptance and the client feels
  understood
• See the person, not his/her weight
• helps the person be more open

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In chronic disease management

• Research supports client centered more effective
• Our job
• facilitate people making healthy lifestyle
  changes
• increase understanding of the process of change
• Behavior change is not an event but a process
• cant view weight management as a diet but
  rather a long term lifestyle venture
• we need to see it this way if we are going to
  help our clients approach it in this way
• Transtheoretical Model of Change
• helpful tool for both our understanding and for
  working with clients

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Transtheoretical Model of Change

• Developed by Pprochaska and Norcross
• five stages
• shows behavior change is not an event but a
  process
• facilitates assessment of a persons readiness
  for change
• helps determine appropriate strategies
• minimizes our and clients frustrations with
  obstacles and set backs
• gives understanding of set backs (relapses)
• pathway to change is rarely a straight one
• helps explain why you may get different results
  with the same treatment

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Stages of Change

• Precontemplation- not thinking of change
• Contemplation- seriously thinking of change in
  the next 6 months
• Preparation- ready to make a change in the next
  30 days or sooner
• Action- actively making the change
• Maintenance- made the change and maintained it
  for 6 months

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Characteristics of Each Stage

• Precontemplation
• dont see behavior as a problem
• not ready to change
• denial
• defensive
• cons greater than pros
• Contemplation
• know behavior is a problem
• thinking of changing
• lack confidence to change
• waiting for perfect time or magic
• cons and pros equal- on the fence

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Characteristics of Each Stage

• Preparation
• ready to make a plan to change
• preparing to change
• need and desire assistance
• want improved health and image
• pros greater than cons
• Action
• practicing new behaviors
• purposeful steps toward change
• enthusiasm and commitment high
• obstacles decreasing
• confidence increasing
• self-efficacy greater than temptations
• at risk for relapse

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Characteristics of Each Stage

• Maintenance
• better self image
• have been doing new behaviors for 6 months
• improved self esteem
• self-efficacy greater than temptations
• may be over confident
• may become complacent
• can relapse
• Consolidation
• the change is made
• does not require focus and attention
• automatic
• new way of doing behaviors

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Reality of Change is A Spiral

• Dont just move through changes easily and
  sequentially
• permanent behavior change takes trials, error,
  and practice
• be prepared for complications
• Relapses occur- moving backwards
• not a negative event but an expected part of the
  change process
• key is to learn from the relapse
• try again using a different strategy
• stress increases risk for relapse
• Success requires determination and persistence

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Need to assess stage individual is in...

• Talk to client
• history
• weight goal/s
• current eating and physical activity
• thoughts on causes and contributions to his or
  her weight
• beliefs regarding weight on his or her health and
  well-being
• readiness to change behaviors
• confidence in his or her ability to be successful
• open-ended questions, reflective listening,
  empathy non-judgmental attitude, past experiences

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and use strategies and techniques appropriate for
the stage.

• Cognitive Processes Emotional Preparation
• Behavioral Processes Physical Actions
• Decisional Balance Internal Pros and Cons
• Goal Setting Specific Action Plan
• Barrier/s Remove Overcome Hurdles
• Relapse Prevention Temptation/s Resistance
• So which strategy for which stage?

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Use Cognitive Processes in Early Stages

• Precontemplation
• raise awareness
• counter defenses with facts
• tap into motivators
• tie to observations about the individual versus
  generic
• not good to ignore resistance to change or denial
  of a problem
• helpful to acknowledge resistance/denial
• Contemplation
• aid self-reevaluation
• promote decisional balance shift
• help individual calculate a cost benefit
  analysis- help them see benefits outweigh the
  costs
• focus on benefits of change

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Use Behavioral Processes in Later Stages

• Preparation
• build confidence
• assist plan development
• reinforce pros of change
• shift from cognitive to behavioral strategies
• increase knowledge nutrition/exercise
• Action
• provide options
• assist with goal setting
• facilitate barrier solutions
• reinforce achievements
• often relapse here because do not have good plan
• cant blame on willpower

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Behavior strategies continued

• Maintenance
• aid relapse prevention
• identify high risk situations
• aid resistance plans
• encourage self-rewards
• stress results were the result of clients
  changes
• Important in all stages
• follow up with the healthcare provider
• supportive relationships

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Behavioral Goals Make the Plan

• Success is increased if the goals/intervention
  is
• realistic
• achievable
• specific
• collaboratively determined
• culturally appropriate
• stage appropriate
• Appropriate stages for developing behavioral
  goals?
• When working on goals it is very important to
  monitor progress.
• Food diary, activity logs, calendars, goal
  sheets, weight change records
• Also very important to reward success.

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Goals lets get specific!

• Vague Between now and my next visit, I will eat
  500 calories less per day.
• Good goal Between now and my next visit, I will
  eat 500 calories less per day by
• choosing an English Muffin with one scrambled egg
  in place of the Biscuit Sausage with Egg
  Sandwich.
• replacing cake/pie with fresh fruit or with
  nonfat Jello with Cool Whip.
• replacing regular soda with water or diet soda.
• Cutting serving size of meat at dinner from 3
  portions to 1 1/2 portions and removing skin from
  chicken and fat from pork or beef.

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More goals!

• Vague Between now and my next visit, I will use
  my pedometer to increase my footsteps per day.
• Good goal Between now and my next visit, I will
  use my pedometer to determine how many footsteps
  I normally take per day, and will increase by 500
  steps per day by
• taking three 10-minute breaks during the day to
  walk either outside or in halls at work.
• Walking for a least 20 minutes every evening
  either outside, on my treadmill, or in place as I
  watch TV.

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Goals and Rewards

• Choose only 2 to 3 goals at a time
• too many at 1 time is a set-up for failure
• People who write down their goals are 80 more
  likely to obtain their goals, whereas people who
  speak their goals are only 10 likely to meet
  their goals.
• Encourage clients to reward themselves
• not food rewards
• can be tangible or intangible
• something desirable, timely, contingent on
  meeting the goal
• numerous small rewards often more motivating then
  working towards a bigger reward that requires a
  lot of effort.

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Shaping Technique

• Behavioral technique which allows selection of a
  series of short-term goals that builds towards an
  ultimate goal.
• Based on premise nothing succeeds like success.
• Two important principles
• consecutive goals that move you ahead in small
  steps are the best way to reach a point
• consecutive rewards keep the overall effort
  invigorated

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Breaking the Chain

• Idea behavior is the result of many things that
  have occurred before-hand
• break a link in the chain and the behavior can be
  broken
• have to identify the different links in the chain
  to figure out the intervention (where to break
  the chain)
• person overeats cookies while watching TV...

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Conclusions

• Use Behavior Therapy to
• facilitate self-change
• help your client help him or her self
• move through the stages of change
• increase knowledge and skills
• overcome barriers
• prevent relapse
• increase self efficacy and self management
• empower and motivate your client
• negotiate goals and interventions

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Best Practices of Effective Counselors

• excellent listening and communication skills
• build rapport and trust with client
• use skill to engage the client and increase
  motivation
• apply stage of change behavior modification model
• use strategies appropriate to clients stage
• personalize program to the individual client
• provide sound options for nutrition, exercise,
  and health goals
• assess clients emotional challenges and assist
  with coping techniques

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Bottom-line

• Successful weight loss is the result of behavior
  changes.
• Behavior changes are made via a complex process
  not as the result of a diet or magic exercise
  regimen.
• To be successful at helping people lose weight,
  you need to be effective at guiding people
  through this process.