However, MI isn’t unique to nutrition and fitness. It has been used in a variety of disciplines for decades (Frey et al., 2011; Heckman, Egleston, & Hofmann, 2010; Lundahl et al., 2013; McMurran, 2009). The techniques
are versatile to all behavior changes, be it ending or moderating drug and alcohol use, medication adherence, or dental care. In fact, MI has been touted as the all-purpose Swiss Army knife of behavior change counseling. However, it’s not magic, and using MI with a client doesn’t guarantee change. It simply increases the probability of change.
A lIttle ABout thIs Book
This book is for students, interns, and professionals in a range of fields providing nutrition and fitness counseling. Whether you are new to this
4 Introduction
work or a seasoned professional, these pages include counseling strategies essential in helping clients make permanent changes in eating and activity.
Nutrition and fitness counseling is occurring in a variety of settings
and continues to grow. Nutrition and fitness professionals must be armed with skills to encourage clients to adopt lasting changes. Practitioners in hospitals, health clinics, doctor’s offices, summer camps, community programs, worksite wellness programs, private practices, and telehealth all benefit from learning how to motivate clients to improve eating and activity patterns.
Professionals such as registered dietitian nutritionists, clinicians,
nurses, wellness or health coaches, community nutritionists, personal
trainers and exercise counselors, PE teachers, and coaches spend their days talking to clients about healthy dietary and exercise changes. What happens to clients when they get home from their appointments? Do they put what they’ve learned into action? This book is for professionals who care about the success of their clients, not just the day, week, or month after their visits, but for years to come.
Health care practitioners may be wondering how MI fits in with the
models, systems, and processes unique to each discipline. For example, in the field of nutrition and dietetics, the Nutrition Care Process (NCP) is the guiding model for providing evidence-based care (Lacey & Pritchett, 2003). The NCP consists of four steps: (1) assessment, (2) diagnosis, (3) intervention, and (4) monitoring/evaluation.
MI does not replace the NCP, but instead is incorporated into each
step. Insights for melding MI and the NCP will be mentioned throughout
the book. Other terms featured in nutrition and fitness settings like scope of practice (Academy Quality Management Committee & Scope of Practice Subcommittee of the Quality Management Committee, 2013a), mindful
eating (Mathieu, 2009), and American College of Sports Medicine (ACSM)
guidelines (Garber et al., 2011) will be addressed in light of MI, making this book a complete resource for practitioners who wish to improve their behavior change counseling skills.
In Part I of this book you will learn about the principles that make
MI effective. In Part II we will take you step by step through a typical MI appointment in nutrition and fitness counseling, learning the various components of a session. Part II introduces the four processes within an MI session: (1) engaging the client, (2) inviting the client to focus on a topic, (3) evoking the client’s feelings about change, and (4) assisting the client in the planning process of making the change. In this section, we will use scenarios and dialogue to demonstrate the four processes and specific communication techniques. It’s one thing to read about a skill or technique, but it’s much more fruitful to see it in action. We hope that these dialogues will help you apply these techniques in your own practice.
Part III includes information on specific MI communication techniques:
Introduction 5
open-ended questions, reflections, affirmations, and summaries. These are known as the microskills of MI and are used throughout each appointment. When used correctly, these types of questions and statements can
demonstrate empathy and help the client consider personal feelings regarding behavior change. In this section you will learn common evoking open-ended questions that are appropriate for nutrition and fitness counseling sessions. We’ll also explain and demonstrate affirmations, reflections, and summaries. You will understand the importance of these skills in promoting client autonomy and moving him or her toward change.
Part IV will give new perspectives on topics that commonly arise in
nutrition and fitness appointments. We’ll address questions unique to nutrition and fitness counseling, such as: How do you dispel diet myths in a nonjudgmental manner? How do you promote realistic goal setting and
help clients avoid setting short-lived New Year’s resolutions? How do you promote fitness and health without leading clients to obsess about weight and appearance? Discussions of weight and health are so common in nutrition and fitness counseling that we devote an entire chapter to helping practitioners navigate this complicated topic with their clients.
The latest research on weight and health is resulting in a shift among
practitioners away from weight-focused counseling toward what’s called
weight-neutral counseling (Ramos Salas, 2015; Tylka et al., 2014).
Researchers are finding that diets, no matter which you use, don’t work (Mann et al., 2007). Dieters lose weight at first, but almost always gain it back along with body insecurities, emotional ties to food, and a sup-pressed metabolism (MacLean, Bergoulgnan, Cornier, & Jackman, 2011; Neumark-Sztainer et al., 2006). Nutrition and fitness professionals who conduct weigh-ins, promote calorie counting, and assign miserable exercise regimens will soon be a distant memory.
Nutrition and fitness counselors are inviting clients to focus on sus-
tainable, more realistic eating and activity patterns, instead of fixating on the scale. By taking the focus off of weight loss and body composition, and instead concentrating on developing a positive relationship with food and exercise, clients can avoid the emotional roller coaster associated with the dieting mindset while improving overall health and wellness. This non-diet approach has been found to be effective in promoting health, especially emotional health, and is preferred by clients (Clifford et al., 2015; Schaefer
& Magnuson, 2014).
Sample MI dialogues throughout the book will remain consistent with
this weight-neutral, non-diet approach, and include concepts such as mindful eating and discovering joyful physical activity patterns.
While it’s entirely possible to use MI techniques in weight-focused
counseling, the risk of doing so includes a vicious cycle of yo-yo dieting, disordered eating patterns, and body dissatisfaction. We believe MI and non-diet approaches make a beautiful marriage. Both involve exploring the
6 Introduction
client’s personal thoughts and feelings about change and promote a non-
judgmental self-exploration.
Food and feelings can be complex. Food, activity, and dieting can be
used as coping tools for negative emotions, making behavior change counseling challenging at times. It can be a relief to remember that nutrition and fitness professionals are part of a client’s health care team and can be the first to identify when a client might benefit from additional services. See more about making referrals to the appropriate health care professionals in Appendix 1, “Making Referrals,” located at the end of this book.
Within one’s scope of practice, a nutrition and fitness counselor
using MI encourages a client to become curious about barriers to change, emotional ties to food and exercise, triggers for overeating, and roots of body image and self-esteem. MI is the perfect vehicle for inviting clients to explore how their nutrition and fitness patterns relate to other areas of wellness. Counselors who are able to bridge the gap between nutrition,
exercise, and motivation will find they are better equipped to help clients actually reach and maintain their health goals.
Not ev
eryone wants to change. However, through the use of strategic counseling techniques, unmotivated clients can become motivated—at
times, even overnight. Mastering client-centered counseling techniques, on the other hand, does not happen overnight. The information provided
in this book will give you tools and techniques to assist your clients and patients in making lifelong dietary and fitness changes. Combine this book with training and practice, and soon you’ll be gliding across the ice with rhythm and grace.
PArt I
Motivational Interviewing Basics
chAPter 1
The Complexities of Lifestyle Changes
The first step towards getting somewhere is to decide that
you are not going to stay where you are.
—UnknoWn
Changing a behavior isn’t easy. While clients have great intentions, they often struggle with consistent follow-through. They have grand hopes and dreams of taking care of their bodies, but then life gets in the way. Whether it’s a new baby, a worrisome diagnosis, a job change, an unsupportive
spouse, a flaky workout buddy, an unrelenting work schedule, or a vaca-
tion, the joys and challenges of life take us off course on the winding road toward health.
Before we can spell out the best strategies for assisting others in making permanent lifestyle changes, it’s important to take a moment and discuss the complexities of change. In order to develop empathy for clients, it’s often helpful to consider your own health patterns. Think about positive behaviors that you do naturally without any prompting. For many, brushing teeth twice a day is an ingrained habit. For the regular teeth brushers, how did it become so easy? Why do you do it? It’s likely because the benefits of the behavior outweigh the costs. Taking a few minutes in the morning and the evening to brush your teeth gives you fresher breath and fewer cavities. Fresh breath improves your social life, and having fewer cavities lowers your dental bills. Taking care of your teeth may reduce oral pain, enhance your smile, and reduce your chance of losing teeth as you age. For regular brushers, the cost of a few minutes each day is worth the benefits of healthy teeth and gums.
Now consider a health behavior change that you’ve wanted to make
but haven’t quite attempted. What’s keeping you from making that change?
Perhaps you’ve been meaning to start flossing your teeth. You know the
benefits of flossing your teeth, and your dental hygienist recommended that 9
10
MI BASICS
you floss daily, but you haven’t started. The cost of flossing is a little higher than the cost of brushing your teeth: it tacks on a few extra minutes to your teeth-brushing regimen. Plus you may have to put up with bleeding
and sore gums at first. While the benefits are similar to brushing, you may not be convinced it’s necessary to maintain dental health. If you aren’t currently flossing regularly, it’s likely you don’t think the benefits outweigh the costs, or maybe you haven’t given it much thought. What would motivate
you to make that change? Consider this question as we explore the com-
plexities of making a behavior change.
stAges oF chAnge
Prochaska and DiClemente hypothesized that there are different stages of change (Prochaska & DiClemente, 1984). A person doesn’t typically wake up one day, decide to change a behavior and then successfully maintain that change until the day he dies. Typically, an individual moves through stages.
These stages of change are part of a behavior change theory known as the transtheoretical model (TTM).
While the TTM was developed around the same time as MI, they are
quite distinct. TTM is a theory, whereas MI was developed from within
practice; it is not a theory but a style and method for assisting others to make changes (Miller & Rose, 2009). However, it’s useful to understand the stages of change that your clients experience in order to more fully grasp and appreciate the efficacy of MI.
There are five stages of change presented by the TTM: precontempla-
tion, contemplation, preparation, action, and maintenance. Each stage is characteristic of certain thought patterns and behaviors.
1. Precontemplation. An individual in the precontemplation stage is either unaware or in denial that a change is necessary or warranted. In the nutrition and fitness counseling world, a client in precontemplation may open an appointment with, “I’m just here because my doctor made me
come. Please don’t take away my favorite foods. I’ve given up smoking and booze, and food is my last vice. You’re going to take it away from me, aren’t you?”
2. Contemplation. An individual in the contemplation stage is aware that a change needs to be made, but has mixed feelings about making the change. A client in this stage of change might say something like, “I probably shouldn’t eat out every day for lunch, but I just get lazy in the morning and I’m always running late, so I hardly ever pack a lunch.” The client has no plans to change and is on the fence about whether doing so would be
worth the effort.
The Complexities of Lifestyle Changes 11
3. Preparation. In the preparation stage, the client is expressing a desire to make a behavior change within the next month and is seriously considering how he or she might go about doing so. A client in the preparation stage of change may state, “I know when I do try to eat more fruits and vegetables, I will need to go to the store more often so that I have fresh produce on hand.”
4. Action. The action stage is most notably the hardest stage; in most cases it requires the client to expend physical energy. The stages before this one requires the client to expend mental energy, but the action stage is where the client actively makes the change he or she has been preparing for. A client in the action stage of change might say, “My doctor told me about my cholesterol last week, so I switched from butter to that fish oil margarine. It doesn’t taste half bad.”
5. Maintenance. Once the client has made the change consistently for 6 months, according to Prochaska and DiClemente, the client is in the maintenance stage of change. Clients who make it to the maintenance stage of change are still at risk for reverting to old patterns. However, the likelihood of maintaining the change is higher now that the change has become a regular part of the client’s life for a significant amount of time. A client in the maintenance stage of change might say, “I’ve been riding my bike to work ever since I got out of cardiac rehab 2 years ago.”
Now and then an individual may move linearly through the stages of
change. What’s more common, however, is for people to jump back and
forth among the stages. Even within a single counseling session, a client might move from precontemplation all the way to preparation and back
down to contemplation. The following narrative demonstrates the fluidity of the stages of change.
Jamie is a college student who decides she’d like to start adding 20
minutes of strength training twice a week to her busy schedule that
includes work, school, and an active social life. She never gave strength training much thought (precontemplation) until she met her boyfriend,
who enjoys lifting weights. He’s an exercise science major and told
her about how lifting weights can help improve muscle tone, bone
strength, and posture. Jamie’s mom always tells her that she slouches,
so she likes the idea that doing strength training exercise might help.
As she considers the change (contemplation) she wonders how she will
fit it into her schedule and how she will learn the exercises. She doesn’t have money for a personal trainer.
One summer, she discovers that her friend lifts weights a few
times a week and asks her to demonstrate how to use the machines
at the gym. Her friend agrees and they set a date for the next week
(preparation). Jamie catches on quickly and
figures out how to squeeze
12
MI BASICS
the time into her schedule by shortening the amount of time she spends
on the cardio machines (action).
However, after the first week she is very sore and so decides to
take a week off to recover (preparation). After the week is over, she
goes on a summer vacation with her family. She restarts her routine 2
weeks later and lifts weights 2 days a week for the first 3 weeks of the fall semester (action). Then midterms hit and she isn’t able to fit her gym routine into her schedule again until the spring semester (contemplation).
Jamie’s spring semester is a little lighter, so she starts going to the gym again consistently for the spring semester and throughout summer (maintenance).
Sounds pretty normal, doesn’t it? Behavior change often involves trial
and error where consistency becomes an elusive goal. The term ambivalence is often used for this indecisive state of being. As a nutrition and fitness practitioner, it’s important to learn how to recognize ambivalence and assist clients as they wade through the muddy waters of behavior
change.
AMBIvAlence 101
An individual who is in contemplation or preparation stages of change is in a state of ambivalence, experiencing mixed feelings about starting something new. It’s almost as if his brain is split in two. Part of him wants to make the change and part of him doesn’t.
Needless to say, the brain isn’t so easily compartmentalized. In fact,
the study of how the brain works and changes is an incredible science.
Scientists seem to be learning more and more about neural plasticity, or the physical changes that occur in our neural circuitry based on our experiences. Consider the teeth brushing and flossing example. When you deviate from your old habits and start to do something new on a consistent basis, such as flossing your teeth, you are essentially growing new neural connections and pruning the old ones back. When you’ve entered into a state of maintenance with this behavior you’ve strengthened these new neural connections, making it easier to continue the behavior.
Motivational Interviewing in Nutrition and Fitness Page 2
