dr. elizabeth detmer, c. psych . sickkids team …...practice & coaching • mastery of a...
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Dr.ElizabethDetmer,C.Psych.SickkidsTeamObesityManagementProgram(STOMP)
TheHospitalforSickChildren
Dr.AnnickBuchholz,C.Psych.CentreforHealthyActiveLiving(CHAL);
PediatricResearchonEatingDisordersandObesity(PREDO)Unit
Outline1. Reviewwhychildrenandteens/familiesarereluctanttotalkaboutweight,bodyimage,ea<ng,&exercise.
2. Learnhowfamiliesandchildrenwouldlikehealthcareproviders(HCP)toapproachandworkonweightissues.3. ReviewfundamentalsofMo<va<onalInterviewingandprac<cespecifictechniques.
“I’ve always known, even in kindergarten, that something was wrong with me . . that I was bigger . . . and that it was my own fault.”
“I’ve always felt - even in kindergarten - that something was wrong with me . . that I was bigger . . . and that it was my own fault.”
16 year old STOMP Patient
KidsarePrejudicedAgainstHeavierPeopleatAge4
Heavier Alfie was less likely to do well in school, to be happy with the way he looks, or to get invited to parties They rated heavier Alfie as more likely to be naughty and as having fewer friends that Thomas to play with
Hill(2013).EuropeanCongressonObesity(ECO).
TeasingandBullyinginAdolescenceAdolescentreportsofwhypeersareteased/bullied,and
observedfrequency(N=1555)
Yaleruddcenter.org(2014);Puhletal.,JSchoolHealth(2011)
AWeightObsessedWorld
SocietalPressures
• InWesternSocietythemediaisapowerfulinLluenceandpressureonyouthtoday
• Bodyimagemessagesareeverpresentandtypicallystate:• Thinwomenarebeautiful,successfulandhappy
• Muscular,leanmenarehandsomeandsuccessful
Grabe et al. Psychological Bulletin (2003)
MixedMessagesintheMediaAroundBodyImageandFood
• 47%ofoverweightgirlsand34%ofoverweightboysreportbeingteasedabouttheirweightbytheirparents
• 72%ofoverweightadultsreportedtheyhadexperiencedweightbiasfromfamilymembersaschildren
PuhlRMetal.,JSchHealth(2011);PuhlRMetal.,PsychBull(2007)
WeightBiasatHome
CultureofValuingThinnessWeightBias
HighBodySelf-ConciousnessLowBodyEsteem
HighWeightPreoccupa<on
Die<ngPrac<ceWeightLossStrategies
Increasedoverea<ngEmo<onalea<ngBingeEa<ng
Shame,guilt,anger,sadnessIncreasedweightover<me
TheNegativeSpiral
WeightBias
BodyImage
• Themostimportantself--esteemdomaininboysandgirls,andmenandwomen.
Harter,1999;A`e&Brooks-Gunn,1989;S<ce&Shaw,2002;Neumark-Sztainer,etal.,2006
• Strongpsychologicalcorrelateofdisordered
ea<ngandobesity.
AChild’s‘Best’BMIMayNeverBeHisorHer‘Ideal’BMI
Key Principles
NeuroendocrineControlofEnergyBalance
Science. Feb 7, 2003
WhoisHealthier?
HealthatEverySize:HAES®
HealthManagement
Aaron12yo,BMI22kg/m2
Plays3hoursofvideogamesanight,isbeingbulliedatschool,
andhasfewfriends.Skipsbreakfast.Sleeps8hoursanight.Liveswithhismomandhasno
contactwithhisdad.
Jeff12yo,BMI22kg/m2
Excelsinschool,hasmanyfriends.Ac<vewithschoolsportsteams.Hassuppor<veparents.Sleeps10hoursanight.Hasnobiochemicalorclinicalevidenceofweightrelatedhealthcomplica<ons.
• Sizeacceptance• Recognizes<gmaandbiases• Understandandvalidatebodyimageconcerns• No-die<ngapproach• Focusonhealthbehaviours,notweight
HealthAtEverySizeFramework
ExplainBeneLitsofHealthBehaviours• ThefirstgoalistoSTABILIZEBMI
• Changesinhealthbehaviourscanresultinsubstan<alhealthbenefitsincludingimprovementsin:
o Lipidprofileo Bloodglucosecontrolo Bloodpressurecontrolo Fitnesso Sleepo Bodyimage
o Self-esteemo Coping
DiscussingWeightwithYouth
• Approachwithsensi<vity“Howdoyoufeelaboutyourhealth,body?”
• Speaktotheirmo<va<ons“Doyoufeelthatyourweightisinterfering?”
• Promote/ProtectBodyEsteem“AtCHAL,wethinkthatallbodyshapesandsizesareaorac<veandcanbehealthy;weareheretohelpyouachieveyourbestphysicalandmentalhealth”
BodyEsteemActivities• Educateaboutmediaanddiscussionaboutbeauty
• Addresssocialanxietyandbodyesteem• Stopweighingyourself-esteem• Tellyourchildthathe/sheisbeau<fulopen
Takinguponesideofaninternalargument,
elicitstheothersideoftheargument
Bem’sselfperceptiontheory• Webecomegraduallymorecommittedtothatwhichwevoice.
• Elicitingcounter-changeargumentsdecreasesthelikelihoodofchange.
Confrontation&defensiveness• Levelofclientdefensivenessisstronglyinfluencedbytheinterviewer
• Acounselor’sconfronta<onelicitsdefensiveness
• Clientdefensivenesspredictslackofbehaviorchange
Whatisthebestwaytohelppeoplelookatthreateninginforma5onand
letitchangethem?
• Empathetic counseling technique to elicit
‘change talk’
• Core principles: • Expressing empathy • Developing discrepancy • Rolling with resistance • Supporting self efficacy
EvidenceforMI–Resnicowetal.,2015
• MIdeliveredbyPrimaryCareProviders&RegisteredDie<<anstoparentsofoverweightchildren(2-8years)over2years
• Compared• Group1:Usualcare• Group2:4PCPMIsessionstoparents• Group3:4PCPMIsessions+6RDsessionstoparents
• Group3experiencedsta<s<callysignificantreduc<onsinBMIpercen<les
EvidenceforMI–Pakpouretal.,2015
• MIdeliveredbytrainedinterven<onists(e.g.RegisteredDie<<ans,ExerciseSpecialists)toadolescents(14–18years)over12months
• Compared:• Group1:UsualCare• Group2:Six40minutesMIsessionwithadolescentonly• Group3:Six40minuteMIsessionswithadolescentplusone60minuteMIsessiontoparents
• Group3showedexperiencedsignificantlyimprovedhealthbehaviorsandgreaterweightloss(BMIzscores)
EightTasksinLearningMotivationalInterviewing
1 OverallSpiritofMo<va<onalInterviewing
2 OARS–ClientCenteredCounselingSkills
3 RecognizingChangeandSustainTalk
4 Elici<ngandStrengtheningChangeTalk
5 RollingwithSustainTalkandResistance
6 DevelopingaChangePlan
7 Consolida<ngCommitment
8 Transi<onandBlending
Motivational Interviewing Training New Trainers, September, 2014
Practice&coaching• Masteryofacomplexskilltakesprac<ce.• Withoutreliablefeedbackoneisunlikelytolearnitwell.• Acoach/teachermustbeabletoobserve.Thetenniscoachhastowatchyouprac<ce;thepianoteachermustlistentoyouplay.
OverallspiritofMI
GoodMI• Talklessthanyourclientdoes• Addressfeelingbeforefixing• ReLlecttwiceforeachquestionyouask• Whenyoudoaskquestions,askmostlyopenquestions• Avoidgettingaheadofyourclient’slevelofreadiness• Rollwithresistanceversusconfront• Elicitchangetalkversusinform/advise• AfLirmeffortandcommitment• Giveuptheexpertrole
FundamentalsofMI-OARS• Openendedques<ons• Affirma<ons• Reflec<ons• Summarystatements
Openendedquestions:• Cannotbeansweredwithayesornoorveryshortphrase
• Examples:“Whatstrategieshaveworkedforyouinthepast?”“Whatkindsofhealthychangeswouldyouliketofocusonthisweek?”
AfLirmations:• Statementsthatrecognizetheclient’semotionsandstrengths
• Examples:“DealingwithweightissuesisdifLicult,”“Youhaveworkedsohard.”
ReLlections:• Letthepatientknownotonlythatyouarelisteningbutthatyouarehearingwhattheyaresaying
• Example:“So,yousayyourchildrenwon'teatvegetables,andtheyareexpensive,butyoufeelyoucanpreparethemforyourself.”
SummaryStatements• Collectingmaterialthathasbeenofferedbythepatientintoaconclusivestatement
• Example:“You'veexpressedconcernaboutyourweight,hypertension,andfamilyhealthhabits.”
FundamentalsofMIAskpermissionto-
• Approachadifficulttopic• Giveadvice
Whengivingop<ons/advice-
• Provideatleast2op<ons• Undersell–“Thismightwork,Idon’tknow”
ExamplesofhowtoapproachdifLiculttopics
• Would it be alright if we discussed your (child’s) weight?
• Are you concerned about your (child’s) health/weight?
• Can I share some information with you about cholesterol levels and why that information can be important?
Givechoices
SedentaryBehaviour
MentalHealth/BodyImage
PhysicalAc?vity
Sleep
Ea?ngBehaviours
SedentaryBehaviourSleep
Topicofyourchoice
Rollingwithresistance• Reflect the resistant statement:
You don’t like this idea. • Reflect the tone of what you are hearing:
You seem to feel hopeless. You’re not happy about . . .
• Reflect ambivalence: On the one hand you want . . . and on the other you don’t think you can . . .
• Acknowledge the resistance process: I’ve gotten us off track here.
• Support choice/control: It’s up to you. You are in charge here.
Rollingwithresistance-Exercise• Writedown1-3resistantorsustaintalkstatementsyouhaveheardfrompa<entsandfamilies• Examples:Ireallyhatevegetables,Ican’texercisebecausemyjointshurt.
• Taketurnsreadingthesestatementstotherestofyourtable.• Collec<velyasatablegiverepliesthatdodgeand/orrollwiththeresistance.Youcanusereflec<ons,reframesorstatementsthatemphasizethatthepa<enthascontrol.
• Writedowntheresponsesyoulikethebest.• Con<nuearoundthetableun<ltheworkshopfacilitatorscall<me.
• Decideasatablewhichareyourfavoritesandsharewiththelargergroup.
Ultimategoal–increasechangeandcommitmenttalk
Typesofchangetalk• Desire–Whydoyouwanttomakethischange?• Ability–Howmightyyoubeabletodoit?• Reasons–Whatisonegoodreasonformakingthechange?• Need–Howimportantisitandwhy(0-10)?
• Commitment–Whatdoyouintendtodo?• Ac<va<on–Whatareyoureadyandwillingtodo?• TakingSteps–Whathaveyoualreadydone?
RespondingtochangetalkElaborate
Askforelabora<onoranexample(itwhatways,how,etc.)Affirma?on
Offeraffirma<on(agree,encourage,praisesupport)Reflect
Reflectwhatthepersonhassaid
Remember–it’saboutthinkingaheadtoavoidtheroadblocks
Bestresponsetoincreasechangetalk“Ireallydon’twanttochangethewayIeatbutIknowthatIshould.I’vetriedbeforeandit’sreallyhard.”
A. Youreallydon’twanttochangeyourea<ng.B. It’spreoycleartoyouthatyououghttomakeachangein
yourea<ng.C. You’renotsureifyoucanchangeyourea<ng.
Bestresponsetoincreasechangetalk“Familymealssoundgreatintheorybutwearetoobusytomakethemwork.Thekids’schedulesareallovertheplaceanditisimpossibleforustositdownatthesame<me.”
A. Becauseofyourfamily’sbusyschedule,youfeellikefamilymealsareimpossible.
B. It’sveryhardtofinda<methateveryonecansitdowntogether.
C. Youliketheideaoffamilymeals.
Bestresponsetoincreasechangetalk“Ihavetobehonest.Ihavenotdonethebreakfastthingatall.Idon’treallyhaveanexcuse.I’vedoneokaywithea<ngaliolebitatlunchandusingtheplatemethodatdinnerbutIjustdon’tlikeea<ngbreakfast.”A. It’sreallyhardtoeatbreakfast.B. You’refeelinggoodabout2outof3ofyourgoals.C. Youyoureallydon’tlikeea<ngbreakfastandyoudon’t
knowhowyouwillworkitintoyourday.
5questionstoincreasechangetalk
• Whywouldyouwanttomakethischange?• Ifyoudiddecidetomakethischange,howmightyougoaboutitinordertosucceed?
• Whatarethethreebestreasonsforyoutodoit?• Howimportantwouldyousayitisforyoutomakethischange,onascalefrom0to10,where0isnotatallimportant,and10isextremelyimportant?
• Whyareyouat___insteadof___[alowernumber]?
Follow-upto5questions• Aperyouhavelistenedcarefullytotheanswerstotheseques<ons:
Givebackashortsummaryoftheperson’smo<va<onsforchange.
• Thenask:Sowhatdoyouthinkyou’lldo?
Listenwithinteresttotheanswer.
Roleplay
Resources
AcknowledgementsDr.JillHamiltonDr.CatherineBirkenDr.AleneToulanyDr.AndreaReginaPree<Grewal,NPDanielleBerard,NPAndreaLeyser,RNMelanieGelfand,MSWAlisaBar-Dayan,RDAlissaSteinberg,RDKelseyGallagher,RDAllisonLougheed,B.S.SejalPatel,PT
Ea<ngDisordersProgram,especially:Dr.WendySpe7gue Dr.JuliePerkinsDr.MarkNorris Dr.ClareRoscoeDr.StephenFeder Dr.MeganHarrisonDr.JuliePerkins Dr.NicoleObeid
CentreforHealthyAc<veLiving,especially:Dr.AnnickBuchholz Dr.LaurieClark FaImaKazoun,ResearchAssociate Dr.StasiaHadjiyannakisCharmaineMohipp,ResearchAssociate
CHEO’sCentreforHealthyAc<veLivingandObesityResearchGroup,especially:Dr.GaryGoldfield
PREDO:NicoleHammond,ResearchCoordinator
PediatricResearchonEatingDisordersandObesity(PREDO)
Thankyou!