MI has its roots in the Transtheoretical Model of Change, or TTM (Prochaska and Marcus, 1994; Callaghan et al., 2010). The TTM has four related concepts
considered central to behavioural change. These are stage of change, self- efficacy, decisional balance and process of change. These will now be explained in relation to exercise.
Stages of change are the client’s current state of behaviour. An example of the stages in relation to exercise is as follows.
1 Precontemplation – not even thinking about exercising.
2 Contemplation – seriously considering exercising.
3 Preparation – making plans to change by joining a gym.
4 Action – exercising regularly at the gym but for fewer than six months.
5 Maintenance – exercising regularly for more than six months.
6 Relapse – reverting to not exercising regularly.
The TTM proposes that individuals progress through a series of stages before they achieve a sustained change in the behaviour. When assessing people’s stage of change the mental health nurse has several tasks to consider, which are shown in Box 11.3.
Box 11.3 Stages of change and the mental health nurse’s tasks
r Pre-contemplation – ask questions about the client’s readiness to change r Contemplation – help person to identify reasons for change
r Preparation – help person determine best course of action, for example joining an exercise group, a gym or using stairs instead of lifts
r Action – help person make a plan to change, for example help negotiate access to facilities, accompany them on brisk walks, enrol them on your unit’s exercise activities
r Maintenance – help person identify and use strategies to prevent relapse, for example ask client to keep a diary of activities and how they feel;
reinforce the positive benefits they identify
r Relapse – help person revisit reasons for change as in contemplation
Self-efficacy is the client’s belief that they have the confidence to change their exercise behaviour, even under adverse conditions like being too tired.
You can assess the client’s self-efficacy levels by asking five simple questions (Callaghan et al., 2010). These are:
Ask the client how confident they feel – from not at all confident scoring 1, moderately confident, scoring 3 or extremely confident scoring 5 – about exercising even when tired, in a bad mood, when the weather is poor, when they don’t have time and even when on holiday.
Individuals with high self-efficacy should feel confident that they could exercise even when faced with barriers such as tiredness, time pressure or a bad mood. Exercise self-efficacy should increase as individuals move through the stages of change towards maintenance.
Practice exercise
Consider the five questions designed to assess self-efficacy for exercising. Answer each question and calculate your own self-efficacy score. A total score close to 5 suggests that you are low in self-efficacy, a total score close to 25 means that you are high in self-efficacy. Consider your total score and reflect what your score might mean for how you can help improve a client’s self-efficacy.
Decisional balance is the client’s assessment of the pros and cons of exercis- ing. You can assess the client’s decisional balance by using the questionnaire in Figure 11.1 designed for this purpose (Callaghan et al., 2010).
Not at all important
Moderately important
Extremely important 1 I would have more energy for my
family and friends if I exercised regularly.
1 2 3 4 5
2 Regular exercise would help me relieve tension.
1 2 3 4 5
3 I think I would be too tired to study after exercising.
1 2 3 4 5
4 I would feel more confident if I exercised regularly.
1 2 3 4 5
5 I would sleep better if I exercised regularly.
1 2 3 4 5
6 I would feel good about myself if I kept my commitment to exercise regularly.
1 2 3 4 5
7 I would find it difficult to find an exercise I enjoy that is not affected by bad weather.
1 2 3 4 5
8 I would like my body better if I exercised regularly.
1 2 3 4 5
9 It would be easier for me to perform routine physical tasks if I exercised regularly.
1 2 3 4 5
10 I would feel less stressed if I exercised regularly.
1 2 3 4 5
11 I feel uncomfortable when I exercise because I get out of breath and my heart beats faster.
1 2 3 4 5
12 I would feel more comfortable with my body if I exercised regularly.
1 2 3 4 5
Figure 11.1 Decisional Balance Questionnaire (continued)
Not at all important
Moderately important
Extremely important 13 Regular exercise would take too
much of my time.
1 2 3 4 5
14 Regular exercise would help me have a more positive outlook on life.
1 2 3 4 5
15 I would have less time for my family and friends if I exercised regularly.
1 2 3 4 5
16 At the end of the day, I am too exhausted to exercise.
1 2 3 4 5
Figure 11.1 Decisional Balance Questionnaire (continued)
Typically, individuals who exercise have a positive decisional balance in that the positive beliefs about exercise outweigh the negative beliefs. In con- trast, the decisional balance of sedentary individuals is generally negative (Callaghan et al., 2010). In addition, as individuals progress through the stages, a systematic shift in decisional balance should occur. Specifically, pros should increase when individuals move from pre-contemplation to contemplation. In contrast, cons should decline progressively in the move from contemplation to action and maintenance.
Practice exercise
Select a client with whom you are working and have a discussion about exercise. Using the decision balance questionnaire as a guide, discuss with the client the pros and cons of exercising. From their responses to these questions, list five pros and five cons of exercising for this client.
The final part of the TTM is the processes of change. Processes of change are any activity that the client does to modify their mood, behaviour, cognition or relationships.
An example of the processes and how you can use them when communicating with clients about exercise are shown in Box 11.4.
Box 11.4 Examples of process of change Name of
process Description
Ask the client to identify 1. Consciousness
raising
Increasing knowledge about the benefits of exercise
Some benefits of exercising 2. Dramatic relief Reacting to warnings about
the risks of not exercising
Their typical reaction to warnings about not exercising
Name of
process Description
Ask the client to identify 3. Environmental
re-evaluation
Caring about
consequences to others of not exercising
How they feel not exercising affects how others see them 4. Self-re-
evaluation
Comprehending the benefits of exercise
How they might feel if they exercised more 5. Social
liberation
Increasing healthy opportunities to exercise
Opportunities to exercise near where they live 6. Self-liberation Committing yourself to
exercise
How committed they are to exercising
7. Helping relationships
Enlisting social support to help you exercise more
Who they can turn to for help to exercise more, e.g. a friend who is a regular exerciser 8. Counter-
conditioning
Substituting alternatives How they can take advantage of opportunities to exercise more, e.g.
asking GP for some exercise on prescription vouchers
9. Reinforcement management
Rewarding yourself How they can reward themselves for exercising more 10. Stimulus
control
Reminding yourself to exercise
Reminders to exercise, e.g. leaving reminders around the house or asking the gym to text a reminder
These ten processes can be categorized into two broad classes, namely Expe- riential and Behavioural. Experiential processes cover individuals’ awareness of how exercise may help them, and their feelings about exercising. Processes 1–5 are examples of experiential processes. Behavioural processes are things that individuals do to help them exercise, such as rewarding themselves when they exercise, having friends who encourage them to exercise and placing things around the house that will remind them to exercise. Processes 6–10 are examples of behavioural processes. People generally use different processes during particular stages of change. For example, individuals in the ‘lower’
stages, namely Precontemplation, Contemplation and Preparation, generally use more experiential and fewer behavioural processes than people in the more active stages, namely Action and Maintenance. In contrast, those in
Action and Maintenance generally use more behavioural and fewer experien- tial processes (Callaghan et al., 2010).
Practice exercise
You are working in a substance misuse treatment centre when you encounter Michael.
Michael has been using illicit substances for many years and has made several attempts to get off drugs and remain ‘clean’, mostly without success. After his most recent attempt he managed to get to the maintenance stage – he remained drug free for nearly two years. However, he has recently relapsed and was referred to your centre by his GP. Using an MI approach, describe how you will work with Michael to help him move from relapse to action in his pursuit of a drug-free lifestyle. Consider how you would demonstrate the essential features of MI, how you can assess Michael’s readiness to change and the application of the five principles of MI in working therapeutically with Michael.
In the final part of this chapter, we want to consider the evidence for the efficacy and effectiveness of MI in mental health care.