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Understanding ambivalence and the change process
Dr Kristen Reyher explains how to motivate lasting change, and why understanding ambivalence and stages of change should change your approach.
Welcome to “Motivating Lasting Change.” I’m Dr. Kristen Reyher, and I’ll be leading you through this three part session of our massive open online course. In this session, we’ll be thinking about how we can change and how we can get our clients to change in their attitude towards and their use of antibiotics. It all starts with communication. You’ve probably heard this said in a number of walks of life, but I really think it’s true. Veterinarians and clients need to speak the same language, perhaps as much figuratively as literally. Stewardship of antimicrobials is a shared responsibility between the vet, often as the prescriber, the farmer who might dose their animals, the client who might give the pills to their cat.
Veterinarians and clients need to be working in conjunction with each other and understanding that they share this responsibility of being good stewards for these medicines. In our group, we’ve done quite a lot of work around participatory approaches. Getting farmers, getting clients, getting the general public to understand the role that they play in being good stewards of antimicrobials and how they can make positive changes in their own behaviours. We also like to understand the motivations and the drivers behind why people feel like they need to use antibiotics in their pets or in their livestock. To do this, we use a communications methodology called motivational interviewing on which quite a lot of these presentations about communication will be based.
This is a great communications methodology that allows veterinarians to uncover the motivations in their clients for the reasons why they might be wanting to or feeling that they need to use antibiotics. It’s great to help us to be able to communicate on an even playing field.
There is also a trust element. And research continually shows us that trust between clients and veterinarians is really key. If we’re not speaking the same language, if we don’t understand where one another is coming from, it’s very difficult for us to make headway in making positive changes in antimicrobial stewardship. When we talk about communication, many vets think that means they need to tell their client more. They need to give them more information. They need to persuade them into a different way of doing things. But it isn’t all about the telling. Many clients are aware.
Research tells us that people in the general public– our pet owners, our livestock farmers– know that there’s a problem with antimicrobial resistance, know that it’s important that they use antimicrobials responsibly. But just knowing that doesn’t always lead us to behave in a different way. And there are lots of barriers for why people find it difficult to be good stewards of these important medicines. Monetary concerns. They really want to use something that works very well for their animal even if it is expensive or sometimes if they don’t have the money, they just can’t afford to treat that infection in the right way. Farmers might have a low capacity for investment.
They might not be able to tear down all the barns and rebuild the farming buildings even though they know that’s what’s best for ventilation of their animals. And farmers and small animal clients often want to ensure that animals get every treatment that they need, that they ensure that they treat them for as long as they need to make sure they’re doing a good job promoting their animal’s health and welfare, making sure that they get the treatment that will knock the disease that they have on the head. It’s not all about the telling. It’s not all about the information and the awareness. There are many things bubbling underneath the surface that we need to consider when talking to our clients.
Evidence based communication can help us have a better relationship with our clients and understand a bit more where they’re coming from. Methodology like motivational interviewing that I spoke about before is very evidence based and can really help us to be better communicators with our clients and with lots of other people in our lives. And to help people along this journey of change, we also have to understand the stages of change. The model I will use to explain this is called the transtheoretical model and is shown here. There are a number of stages starting with the pre-contemplation stage. People in pre-contemplation do not intend to take action in the foreseeable future, usually not even in the next six months.
Being uninformed or under-informed about the consequences of their behaviour may cause people to be in the pre-contemplation stage. Multiple unsuccessful attempts at change can lead to demoralisation about the ability to change and to do things differently in our lives. The contemplation stage is the stage in which people intend to change in the next six months. People at this stage are more aware of the pros of changing, but they’re also acutely aware of some of the drawbacks. And they weight the costs with the benefits of changing. And this can produce in them some ambivalence that can cause them to remain in this stage for long periods of time.
When people get to the preparation stage, they’re often ready to take action in the immediate future, probably in the next month. Typically, they’ve already done something of action in the past year. So maybe you’ve gotten the client to start vaccinating their animals. And maybe now they’re ready to consider a diet change for their animals. People in this stage have a plan of action. They might be ready to change their herd health plan. They might want to consult an expert in a certain area of their pet’s health. Or they might be enacting a self change approach to target their own or their pet’s obesity.
Then people often move to the action stage, where they have made specific overt modifications to their lifestyles within the past six months. Action is observable. And so in some processes of behaviour change, the whole process has been equated with action. But in this model, action is only one of the five stages. It’s a great to stage. People are changing things. But it’s still just one of these stages. Then people move on to maintenance, which is the stage where they’ve made these modifications, and then they’re working to prevent going back to their own ways. They don’t often apply a change process as frequently as people in action, but they’re less tempted to go back to how they used to be.
And they grow increasingly more confident that they can continue with the good changes they’ve made for their own health or for their animal’s health. Ambivalence is really wanting to do things on the one hand, but finding arguments within yourself for reasons why you shouldn’t do them on the other hand. Let’s take an example of a farmer that you might work with. The farmer might say, on the one hand, I’m proud of my farm. I want to be seen as responsible with my medicines. But on the other hand, I’m worried that if I cut back on these important medicines, my cows could suffer, and their health and their welfare might not be as good as it can be.
You understand this ambivalence of how the farmer can want both things at the same time and have an argument going on within themselves. And this manifests in the way that people speak. So when they say, I’m proud, I want to be seen as responsible, we call this change talk. They’re talking in such a way that they show they want to change, they’re ready to change, they will do things differently. But if they’re making excuses or thinking up reasons why they can’t do that, which we all do, we call this sustained talk. Telling ourselves let’s just carry on with the status quo.
Let’s just keep doing things the way we have been doing them because it’s difficult and sometimes frightening to change. And what we know is that ambivalence is a totally normal part of contemplating change. We all go through this. We all have this discussion inside ourselves when we’re thinking about making a change in our lives. But what we also know is how you as a veterinarian speak with your clients can influence how this manifests in talking about their treatment of their animals, their medicine use, and a number of different areas. The way we invite them to think about these ideas can really change the conversation. And the way we talk can lead them potentially to a different place.
We know that telling clients, that pushing them, that persuading them into our way of thinking and trying to do it in that way just invokes something that we call psychological reactants. They put their hands up, they push back, and they try to think of reasons why they shouldn’t do the things that we are telling them that they should do. They speak with sustained talk by saying, I can’t do this. I’m worried about this. I’m not ready for this change.
But we know when we ask them to consider a different way, when we invite them to think about what’s going on within theirselves and in their operations or their homes, when we engage with the things that are really important to them, they speak in a way that they might be able to change. Oh, now that we’re discussing this, I think I might want to do something differently. I am interested in this. So I will change the way that I take care of my animals. And moving the conversation to this way can bring them around to understand where we’re coming from because they’re thinking about it within themselves and finding those answers within themselves.
And what we know is that as people speak, as we hear ourselves speak, we believe the things we tell ourselves much more than the things that others might tell us. So if we hear ourselves saying, I will be a better steward of antimicrobials, I will vaccinate my animals, I will think about better ways to maintain my animal’s health, we’re much more likely to do so. In the next session, we’ll talk about some of the potential conversations we might have with our clients and how we can use better communication techniques to lead our conversations to a more positive way of change in all of our consultations.
The next three steps, that make up the motivating lasting change activity, have been developed by Dr Kristen Reyher, and will explain how to motivate and engage in lasting change, not just in practice, but also with clients.
This video will demonstrate the importance of understanding ambivalence and the stages of change.
Communication
Due to the shared nature of the responsibility of stewardship, everyone needs to be ‘speaking the same language’ and working in conjunction with each other, so participatory approaches are key to improving understanding of this topic. For example, the bottom-up approach that was described by Lisa Morgan in step 3.5. It’s important for vets to understand the motivations and drivers behind client’s behaviours. Trust between veterinarians and clients is also crucial.
Communication is not all about vets providing clients with a huge amount of information. In fact, many people are already aware that there’s a problem with antimicrobial resistance, however this will not always mean their behaviour changes, due to factors such as monetary concerns or a low capacity for investment.
How vets communicate with clients will be further explored in steps 3.14 and 3.15.
Stages of change
- Pre-contemplation stage: when people do not intend to take action in the foreseeable future, due to being uninformed about the consequences of their behaviour.
- Contemplation stage: when people intend to change within the next 6 months and are aware of the pros of changing, but also the drawbacks.
- Preparation stage: when people are ready to take action in the near future and they have a plan of action.
- Action stage: when people are making observable changes in their behaviours and lifestyles.
- Maintenance stage: when people have made modifications and are working to prevent falling back into old routines.
It’s really important to understand what stage of change your client is in so that you know how to approach them when suggesting change. This will have a significant impact on how they react to certain approaches, as you will learn in the next step.
Ambivalence
Ambivalence is a totally normal part of contemplating change and is when you want two opposing things at once. It’s almost as if you have an argument going on in your head.
This can sometimes be seen in the way people talk: if they show they want to change, this is change talk, and if they are giving reasons for not changing, this is sustain talk. When talking to clients, you should always accept this and ask more open questions, where you can fully discuss both sides, and then they may start to use more change talk.
Do you have any examples where you have recognised a client in a particular stage of change, and this made you change your approach? Have there been any times where you maybe haven’t recognised what stage of change a client has been in, and this hindered your conversation? Use the comments section to discuss.
Please find a downloadable copy of the PowerPoint slides used in the video in the downloads section below.
This article is from the online course:
Antimicrobial Stewardship in Veterinary Practice
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Antimicrobial Stewardship in Veterinary Practice
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