ebook
THE GUILFORD PRESS
MOTIVATIONAL INTERVIEWING
IN NUTRITION AND FITNESS
Applications of Motivational Interviewing
Stephen Rol nick, Wil iam R. Miller,
and Theresa B. Moyers, Series Editors
www.guilford.com/AMI
Since the publication of Miller and Rollnick’s classic Motivational Interviewing, now in its third edition, MI has been widely adopted as a tool for facilitating change. This highly practical series includes general MI resources as well as books on specific clinical contexts, problems, and populations. Each volume presents powerful MI strategies that are grounded in research and illustrated with concrete “how-to-do-it” examples.
Motivational Interviewing in Health Care:
Helping Patients Change Behavior
Stephen Rollnick, William R. Miller, and Christopher C. Butler
Building Motivational Interviewing Skills: A Practitioner Workbook
David B. Rosengren
Motivational Interviewing with Adolescents and Young Adults
Sylvie Naar-King and Mariann Suarez
Motivational Interviewing in Social Work Practice
Melinda Hohman
Motivational Interviewing in the Treatment of Anxiety
Henny A. Westra
Motivational Interviewing, Third Edition: Helping People Change
William R. Miller and Stephen Rollnick
Motivational Interviewing in Groups
Christopher C. Wagner and Karen S. Ingersoll, with Contributors
Motivational Interviewing in the Treatment of Psychological Problems, Second Edition
Hal Arkowitz, William R. Miller, and Stephen Rollnick, Editors
Motivational Interviewing in Diabetes Care
Marc P. Steinberg and William R. Miller
Motivational Interviewing in Nutrition and Fitness
Dawn Clifford and Laura Curtis
MOTIVATIONAL
INTERVIEWING
in Nutrition and Fitness
DAWN CLIFFORD
LAURA CURTIS
Series Editors’ Note by Stephen Rol nick,
Wil iam R. Mil er, and Theresa B. Moyers
The Guilford Press
New York London
Copyright © 2016 The Guilford Press
A Division of Guilford Publications, Inc.
370 Seventh Avenue, Suite 1200, New York, NY 10001
www.guilford.com
All rights reserved
Except as indicated, no part of this book may be reproduced,
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or by any means, electronic, mechanical, photocopying, microfilming,
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Printed in the United States of America
This book is printed on acid-free paper.
Last digit is print number: 9 8 7 6 5 4 3 2 1
LIMITED DUPLICATION LICENSE
These materials are intended for use only by qualified professionals.
The publisher grants to individual purchasers of this book nonassignable permission to reproduce all materials for which permission is specifically granted in a footnote.
This license is limited to you, the individual purchaser, for personal use or use with individual clients. This license does not grant the right to reproduce these materials for resale, redistribution, electronic display, or any other purposes (including but not limited to books, pamphlets, articles, video- or audiotapes, blogs, file-sharing sites, Internet or intranet sites, and handouts or slides for lectures, workshops, webinars, or therapy groups, whether or not a fee is charged). Permission to reproduce these materials for these and any other purposes must be obtained in writing from the Permissions Department of Guilford Publications.
The authors have checked with sources believed to be reliable in their efforts to provide information that is complete and generally in accord with the standards of practice that are accepted at the time of publication. However, in view of the possibility of human error or changes in behavioral, mental health, or medical sciences, neither the authors, nor the editor and publisher, nor any other party who has been involved in the preparation or publication of this work warrants that the information contained herein is in every respect accurate or complete, and they are not responsible for any errors or omissions or the results obtained from the use of such information. Readers are encouraged to confirm the information contained in this book with other sources.
Library of Congress Cataloging-in-Publication Data
Names: Clifford, Dawn, author. | Curtis, Laura, author.
Title: Motivational interviewing in nutrition and fitness / Dawn Clifford, Laura Curtis.
Description: New York : The Guilford Press, [2016] | Series: Applications of motivational interviewing | Includes bibliographical references and index.
Identifiers: LCCN 2015042791| ISBN 9781462524181 (paperback : acid-free paper) | ISBN 9781462524198 (hardcover : acid-free paper)
Subjects: LCSH: Nutrition counseling. | Physical fitness. | Motivational interviewing. | Health promotion. | Psychotherapist and patient. | BISAC: MEDICAL / Nursing / Nutrition. | PSYCHOLOGY / Psychotherapy / Counseling.
| MEDICAL / Sports Medicine.
Classification: LCC RM218.7 .C55 2016 | DDC 615.8/54—dc23
LC record available at http://lccn.loc.gov/2015042791
About the Authors
Dawn Clifford, PhD, RD, is Associate Professor and Director of the Didac-tic Program in Dietetics in the Department of Nutrition and Food Science at California State University, Chico. In addition, she cofounded and is currently Director of FitU, a peer mentoring nutrition and exercise counseling program on campus. She received the Outstanding Dietetics Educator
Award from Nutrition and Dietetic Educators and Preceptors, a practice
group of the Academy of Nutrition and Dietetics. Dr. Clifford conducts
research and is an accomplished speaker in the areas of motivational interviewing and non-diet approaches to health and wellness. She has published several research articles in the Journal of Nutrition Education and Behavior and written curricula for Today’s Dietitian and Nutrition Dimensions.
She is a member of the Motivational Interviewing Network of Trainers
(MINT).
Laura Curtis, MS, RD, is Director of Nutritional Services at Glenn Medical Center in Willows, California, where she provides clinical nutrition services to patients in acute care and is a nutrition therapist for the outpatient clinic. In addition, she serves as a preceptor to undergraduate dietetic students and is a part-time lecturer at California State University, Chico.
Ms. Curtis has extensive training in motivational interviewing at both the undergraduate and graduate levels. As a nutrition therapist, she provides counseling to patients with conditions such as diabetes, heart disease, and disordered eating, and to those considering bariatric surgery. In her counseling, she pairs motivational interviewing with the non-diet principles of intuitive eating and Health at Every Size.
v
Series Editors’ Note
Health care practitioners are under strain to “make the patient change”
when it comes to eating right and exercising. Colleagues make referrals for behavior change counseling with certain goals in mind. As the recipient of the referral, it’s easy to feel pressured into giving advice when your client so clearly needs to make lifestyle changes.
Motivational interviewing (MI) was developed to improve the conver-
sation about behavior change. It started in the addictions field more than 30 years ago and was gradually refined, subjected to research scrutiny, and extended into other fields. This book provides a good example of this extension, since many of the challenges that arise in other fields converge on the subjects of eating and exercise: we can’t make people change, only they can; reluctance to change is a widespread puzzle; and change itself is often not as simple as we would like it to be.
The authors of this book highlight and illustrate these themes from the first chapter to the last, and point to how practitioners might adjust their style and techniques to achieve outcomes that are more satisfying for all involved. The familiar exchanges about diet and exercise turn into something that is unique to each individual, allowing practitioners to develop their skills as they discover the motivations that drive the client.
Some of the shifts required to use MI well are quite radical. For exam-
ple, one needs to view clients as people with strengths, not just as patients with a list full of pathologies. Empathic listening is key for not only keeping the conversation grounded in the individual, but also gently pointing the conversation in the direction of change, and paying attention to the client’s language of change.
In one sense, this book is an invitation to change for practitioners
themselves—changing the way they execute nutrition and fitness counsel-
ing. Using MI can involve far less strain and tension, in that you don’t have vii
viii
Series Editors’ Note
to come up with all the answers yourself—that’s the client’s task. On the other hand, this invitation also involves a kind of listening and caring in the service of change that requires patience, curiosity, and thoughtfulness.
The book shines with these qualities, and we welcome it with open arms
into the series on applications of MI.
Stephen Rollnick, phD
William R. milleR, phD
theReSa B. moyeRS, phD
Contents
Introduction
1
PArt I. MotIvAtIonAl IntervIewIng BAsIcs
1. The Complexities of Lifestyle Changes
9
2. The Spirit of Motivational Interviewing
25
PArt II. the Four Processes oF MotIvAtIonAl IntervIewIng
3. Engaging and Focusing
41
4. Evoking
58
5. Planning for Change
73
PArt III. MAsterIng the MIcroskIlls: oArs
6. Open-Ended Questions
91
7. Affirmations
108
8. Reflections
120
9. Summaries
134
ix
x Contents
PArt Iv. Beyond the BAsIcs
10. When Clients Aren’t So Sure about Change
147
11. What to Do When There’s Little Time
161
12. Clarifying Health Misinformation and Exploring Unhealthy Beliefs
175
PArt v. A closer look At MotIvAtIonAl IntervIewIng
In nutrItIon And FItness IndustrIes
13. Putting Motivational Interviewing to Work in Nutrition Counseling
191
14. Putting Motivational Interviewing to Work in Fitness Counseling
212
15. Putting Motivational Interviewing to Work to Address
232
Weight Concerns and Disordered Eating
Appendix 1. Making Referrals
251
Appendix 2. Additional Resources
256
References
261
Index
269
Purchasers of this book can download the handouts
from www.guilford.com/clifford-forms
for personal use or use with individual clients.
MOTIVATIONAL INTERVIEWING
IN NUTRITION AND FITNESS
Introduction
Watch ice skating on television and notice how the skaters glide across the ice with ease and grace. Spins and jumps look effortless. Even on a bad day, their confidence on the ice and timing with the music are enough to bring fans to their feet in applause. It looks easy. Anyone who has stepped out onto the ice knows that without years of training, ice skating can be a painful experience. One wrong step on that smooth, slippery surface can bring you falling to your knees. It’s a lot harder than it looks.
Similarly, you may be wondering about counseling in the nutrition and
fitness fields. How hard can it be? Who wouldn’t want to change their eating and exercise patterns for the better? Perhaps you made some changes yourself in these areas and are quite proud of your accomplishments. Possibly, you are a fan of healthy eating and being active. However, having healthy lifestyle patterns doesn’t automatically make you an expert in
counseling others to follow your lead.
Thanks to courageous efforts by public health educators, medical pro-
fessionals, and even physical education teachers, we all by now know the importance of keeping our bodies healthy. We also know it’s not easy to do, and that even despite a firm conviction to eat well and exercise, our motivation to do so waxes and wanes. One day you might wake up fueled by your intention to start eating more fruits and vegetables. You head to the store, buy a few different varieties, take them home, and incorporate them into your meals and snacks. The next day is a little busier, and you aren’t able to get to the grocery store, so you end up eating a chocolate chip muffin from the vending machine in your office.
Clients are often ambivalent about change. Just as the definition of
ambivalence states, clients frequently experience “simultaneous and con-tradictory attitudes or feelings” about changes regarding nutrition and exercise ( www.merriam-webster.com). A young working mother wants to be fit and healthy so she can keep up with her children and be active in 1
2 Introduction
their lives for years to come. However, when she leaves her children in the evening to go to the gym, she feels it takes away from their quality time as a family.
How would a nutrition or fitness professional help motivate this
mother to incorporate regular physically activity into a busy and exhausting life? Would you give this mother a list of reasons to stay faithful to her gym routine? Would you warn her of the negative health outcomes if she
doesn’t? This directive style of counseling typically backfires, decreasing the likelihood of long-term change.
A client’s motivation can be strongly influenced by a health profession-al’s communication style. Imagine you were the working parent described above who is ambivalent about exercising regularly. How would you want
your counselor to approach the topic? Choose from Counselor A or B
below:
• Counselor A tells you what to do and then tries to convince you by
telling you all the horrible things that might happen to you if you
don’t.
Or
• Counselor B listens to your concerns and desires, answers your ques-
tions, and is nonjudgmental and respectful.
Chances are good that you would prefer to work with Counselor B. As
individuals, we like to be in charge of our own health decisions, and we feel most respected when we are heard and our feelings are considered.
MotIvAtIonAl IntervIewIng BAsIcs
Motivational interviewing (MI) is “a collaborative, goal-oriented style of communication with particular attention to the language of change. It is designed to strengthen personal motivation for and commitment to a specific goal by eliciting and exploring the person’s own reasons for change within an atmosphere of acceptance and compassion” (Miller & Rollnick, 2013, p. 29). William Miller and Stephen Rollnick developed MI and published their first book in 19
92. While this client-centered counseling style has evolved over the last few decades, their third edition continues to represent MI as an empathetic listening style that supports clients in convincing themselves that they ought to change.
The primary goal of MI is to increase the client’s interest in making a positive change through evoking his or her interest in the new behavior and disinterest in maintaining status quo. In MI, certain counseling techniques
Introduction 3
are used to encourage clients to explore and resolve ambivalence. In addition, the counselor helps the client see how a behavior change might align with future goals and values. Most important, an MI counselor nurtures
the client’s hope and confidence.
Clients typically know what they should do with regard to eating and
physical activity, but there are many reasons why they don’t. Counselors who use an MI style assume their clients are the experts. The client knows what works best, and the nutrition or fitness counselor is simply there to help the client figure it out.
As presented by Miller and Rollnick, a counselor who uses MI is like
a guide dog for an individual with impaired vision. The person with the vision impairment knows where she would like to go. In the same way, a
client seeking assistance in making health behavior changes knows which changes she would like to make. However, she needs a guide dog—the
clinician—to help navigate the obstacles along the way.
In general, lecturing, confronting, coercing, or threatening the client doesn’t work. In the same way, a guide dog is not going to pull his owner toward the post office if the owner really wants to go to the park. But the guide dog can walk alongside the owner and help her not fall into holes or run into poles.
This gentle guiding style used in MI puts the client in charge, pro-
moting adherence to a specific behavior change. The client begins taking ownership of the behavior; it becomes the client’s goal, not to please the counselor, but because it is important to the client.
Motivational interviewing is an exciting way of talking about change,
which many researchers have demonstrated to be effective within the realm of nutrition and fitness (Armstrong, Mottershead, Ranksley, Sigal, & Campbell, 2011; Bean et al., 2015; Campbell et al., 2009; Christison et al., 2014; Neumark-Sztainer et al., 2010; Van Keulen et al., 2011; MacDonell, Brogan, Naar-King, Ellis, & Marshall, 2012; Miller et al., 2014).
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