Motivational Interviewing in Nutrition and Fitness

by Dawn Clifford

  Understanding the concept of neural plasticity may help you under-

  stand why some habits are so hard to break. In its most basic form, a habit is just a particular pattern of neural connections. However, connections made over a long period of time or during a significant trauma will be more entrenched than others. At first, it can be uncomfortable to maintain a change, not because it is particularly hard to do, but because you are rewiring your brain. New behavior takes more mental energy and attention,

  The Complexities of Lifestyle Changes 13

  whereas the old habit has become automatic. Ambivalence may simply be

  rooted in the decision to do something uncomfortable or unfamiliar. Falling back into old habits is often a welcomed comfort when change becomes unnerving or mentally taxing.

  Ever-changing neural connections make the process of change a work

  in progress. A person can ebb and flow through the stages of change before their new behavior takes on any sense of permanence. A person experiencing ambivalence thinks change sounds good, but still has some reservations.

  He or she may start voicing reasons to make a change, but not make any

  commitments. Feeling two opposing

  ways about a behavior change is a Feeling two opposing ways about

  normal part of the change process. a behavior change is a normal

  It isn’t something to avoid, but some-

  part of the change process.

  thing to embrace, contemplate, and

  move through with your clients.

  In the following example, a middle-aged woman with newly diagnosed

  diabetes expresses mixed feelings about eating breakfast after years of skipping the morning meal.

  “I stopped eating breakfast in high school. I was never hungry, and

  I always thought it would help me control my weight. Not that it

  really helped. My weight has been up, down, and all around. Now

  my doctor is putting me on medication and says if I don’t eat, I could

  pass out. I’m just not hungry in the morning; it makes me feel sick

  just thinking about it. I hope I don’t pass out and end up back in the

  hospital.”

  This next example highlights a man’s ambivalence toward joining a

  tennis club after recovering from injuries he sustained during a severe car accident.

  “I know I’ve got to get back into a regular exercise routine if I want to gain back my full function. My physical therapist says I’m ready, but

  I just don’t know now. I guess I don’t want to push myself. There’s a

  lot of stuff I just can’t do. But I know if I don’t do anything, it will just get worse.”

  Spending time with ambivalence tends to help a client move through

  it. People tend to avoid it because it can be frustrating and uncomfortable to focus on conflicting priorities without making a decision. As a guide, you can shine a light on your client’s ambivalence. When you home in on the ambivalence in a nonjudgmental way, your client can acknowledge the discrepancy, free from pressure. If ready to make a change, your client

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  MI BASICS

  may want to start discussing strategies to adapt the change into everyday life.

  listening for Ambivalence: the heart of MI

  When listening for ambivalence, you will begin to hear client remarks both in favor of and opposed to making a behavior change. Comments made

  by the client that support change are known as change talk. Change talk sounds like this:

  “I don’t want to end up on dialysis like my grandmother.”

  “My friend has had a lot of success by switching out her soda for

  water. I might talk to her and try it out myself.”

  “I’m tired of feeling sluggish. I can’t believe how out of breath I get when I walk up a set of stairs.”

  Comments made by the client that support status quo are known as

  sustain talk. Sustain talk sounds like this:

  “The last diet I went on sent me to the poorhouse. I don’t have the

  money to eat like that now that I’m retired.”

  “There’s no way I can eat in the morning. I hardly make it to work on

  time as it is.”

  “By the time I get home, I’m exhausted. I can’t imagine going to work

  out.”

  Often clients will speak change talk and sustain talk within the same

  sentence or dialogue. Ambivalence sounds like this:

  “I know I’d save money if I cooked more meals at home, but I hate

  doing dishes and cleaning the kitchen. When all is said and done,

  it’s easier just to get takeout.”

  “It wouldn’t kill me to wake up a few minutes earlier, as long as I

  remember not to hit snooze too many times. Sometimes on cold

  mornings, I just can’t help it.”

  “I went for a walk the other day, but it was hot and humid. I did feel

  better after I went, but man, I hate this time of year.”

  “I’d really like to learn how to play tennis, but I might make a fool of myself.”

  A good listener tunes his ears to his client’s change talk and sustain

  talk. Change talk often predicts actual behavior change. Therefore, the practitioner elicits and highlights change talk throughout the MI session.

  This attribute of MI is a common thread revisited throughout this book.

  The Complexities of Lifestyle Changes 15

  the root of Ambivalence

  Ambivalence is often rooted in a discrepancy between an individual’s values and actions. A client might value health and fitness, but think there is insufficient time to be more physically active. This results in a mismatch between where the client is and where the client wants to be. As the practitioner, part of your job is to help your client see that current patterns conflict with his or her values or health goals. In MI, you do this with great care using a curious, nonjudgmental stance, as in the script below:

  pRactitioneR: You said you’ve wanted to try out a yoga class at your

  gym for a long time. What do you think is keeping you from going?

  client: I don’t know, I’m probably just afraid to try something new. It will take me a while to get the hang of it, and I have to figure out

  if it’s worth the risk of embarrassment.

  pRactitioneR: You’re concerned others might make certain judg-

  ments about your ability to do yoga.

  client: Yes, I hate to admit it, but it’s true.

  pRactitioneR: And yet you keep putting that on your to-do list.

  client: I want to be healthy, for one. Plus, my friends talk about yoga all the time. I want to feel like I can join in on their conversation.

  And I have really challenging teenagers who are pushing my but-

  tons lately. I know I could use a way to de-stress.

  pRactitioneR: You value your health and recognize that managing

  stress is an important way to stay healthy. Yoga has been a per-

  sonal goal and interest for a long time now, and you’re hesitant to

  get started. You sound pretty confident that if you got over some

  of your fears of surviving the first class, yoga would benefit you in

  a lot of ways. What do you think you will do?

  client: Yes, I know if I just did one or two classes, I’d be fine. I think if I make sure I go to my first class with one of my friends, I won’t

  be as worried about the other people in the room.

  Motivation for change is likely to increase when the client recognizes

  there is a discrepancy between a current choice and a personal goal. In the example above, the client is choosing

  to not attend the yoga class despite an

  Motivation for change is likely

  interest in doing so. The practitioner to increase w
hen the client uses reflective listening to help the recognizes there is a discrepancy client see this discrepancy, while giv-between a current choice and a

  ing the client full autonomy to attend

  the yoga class or not attend the yoga

  personal goal.

  class.

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  MI BASICS

  There were several examples of change talk in this brief dialogue,

  including “I want to be healthy,” “I want to feel like I can join in on their conversation,” and “I could use a way to de-stress.” In short, MI techniques highlight for clients where they are and where they hope to be.

  AMBIvAlence In dIsguIse: when your clIent wAnts the QuIck FIx

  There will be times when your client may not sound ambivalent. In fact, she may even sound excited and eager to change. However, her desire may be short lived. What happens in a few days, weeks, or months when she

  no longer feels like her changes are “working”? Year after year, millions of Americans make New Year’s resolutions. However, only an estimated

  40–46% of those who commit to a New Year’s resolution are successful

  at maintaining the change 6 months later (Norcross, Mrykalo, & Blagys, 2002).

  Given the high failure of self-change, it’s hard to explain why people

  make resolutions. Perhaps it’s the anticipation of the improved health or the psychological impact such as a boost of pride or confidence. Some researchers believe individuals like to attempt behavior changes because it gives them a feeling of control even if it doesn’t work out in the end (Polivy & Herman, 1999, 2000).

  Many turn to dieting in an effort to control food and weight when

  other areas of life are feeling out of control. Most overestimate the degree of control they have over their size and shape, ignoring the genetic determinants. It’s easy to be lured in by images of thin or muscular bodies seen in the media, and consequently set unrealistic expectations and goals for their own weight and shape.

  At the beginning of the New Year, clients believe the change they

  desire is easy to achieve, and their motivation is high. What is the result of setting unrealistic expectations for a behavior change? Goals are not met and clients become frustrated, discouraged, and they often throw in the towel. The phenomenon of attempting a behavior change with high hopes

  of successful outcomes has been called the false-hope syndrome (Polivy & Herman, 1999, 2000).

  False-hope syndrome is a matter of overconfidence. It’s hard not to feel overconfident when diet programs, in an effort to sell products, play into people’s fantasies that they can change easily and see results quickly. Positive outcomes are routinely promised without any scientific evidence to support long-term success. Dieting researchers Herman and Polivy found that those who attempted to make a change and failed reported feeling worse

  about themselves and saw themselves as failures (Polivy & Herman, 1999).

  Often clients attempt extreme dieting measures with the intention of

  changing temporarily for a big event such as a wedding, class reunion, or beach vacation. In a research study on brides and bridesmaids, 53% planned

  The Complexities of Lifestyle Changes 17

  to lose weight for their weddings and 40% planned to do so through dieting (Prichard & Tiggemann, 2008).

  What does this mean for nutrition and fitness practitioners? First, your client may not express any ambivalence, but that does not necessarily mean that he will succeed at making and sustaining a behavior change. Your client may seem eager to get started, and you immediately peg him as someone who is in the preparation stage of change. However, he may be looking

  for the quick fix or the magic bullet. At the infancy of a behavior change there can be excitement and curiosity, while the actual day-in and day-out efforts may become tedious and tiring. Furthermore, if the client has certain expectations in terms of outcomes or extrinsic reward, and those are not immediately noticed, he may lose steam.

  A client who is a chronic yo-yo dieter may be excited to start another

  diet and anticipates immediate weight loss. However, if you’re offering a non-diet approach that promotes taking the focus off of weight and onto health, you may receive some initial apprehension. In other words, the client may be in the preparation stage of change for starting another diet, but in the precontemplation stage of change for exploring a more realistic and balanced approach. She may be expecting an appointment filled with diet rules and lists of foods she’s allowed to eat and foods she’s not. Instead she gets evoking questions that invite her to explore emotions that drive eating and the etiology of her body image and binging behavior.

  Clients often experience black-and-white thinking when it comes to

  nutrition and physical activity. Some experience rapid and extreme wavering back and forth from carefully counting calories and obsessively going to the gym to eating out all the time and snacking on sweets or salty foods at night to unwind. A client may state, “I’m good on the weekdays and then I let loose on the weekends.” This all-or-nothing mentality sends clients on a vicious cycle starting with restricting favorite foods, skipping meals and snacks, or starting a tedious exercise regimen. Feelings of hunger and deprivation often lead to late-night treks to the kitchen (Polivy, Coleman, & Herman, 2005).

  Binges are followed by feelings of guilt and shame, which start the cycle over again, as clients go all in with a new diet scheme. This cycle has been described by many as the dieter’s cycle, or the diet–binge cycle (Figure 1.1).

  Presenting an Alternative Approach to the Quick-Fix diet

  How do you help clients recognize the Invite clients to share their emotionally exhausting consequences stories, reflect on their dieting of dieting and replace this pattern woes, and offer a new approach with long-term solutions? Invite cli-focused on variety, balance,

  ents to share their stories, reflect on and moderation, instead of their dieting woes, and offer a new restriction, avoidance, and

  approach where lifestyle changes desperation.

  can be about variety, balance, and

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  MI BASICS

  Negative

  Thoughts

  Diet

  Shame

  (Restrictions)

  Overeating

  Deprivation

  FIgure 1.1. The diet–binge cycle. Copyright 2013 by Judith Matz, judithmatz.com.

  Reprinted by permission.

  moderation, instead of restriction, avoidance, and desperation. Clients may not be expecting a gentle approach toward self-care, but often find that baby steps and self-compassion are the way to permanent change.

  At times, the client’s expectations for an appointment don’t line up

  with the services offered. Most expect to meet with a nutritionist or dietitian and receive basic nutrition education. Most expect to meet with a fitness expert and receive a list of recommended exercises. Instead, MI puts the client in the driver’s seat, where the client is encouraged to create his own list of changes and explore personal reasons for embarking on these new behaviors. This style takes the place of lecturing clients on why they need to change and how to do it. While nutrition and fitness education may still be part of the appointment, it often takes a back seat to what the client needs most—motivation to change. In the following dialogue, a client shares her struggles to maintain dietary restriction while the practitioner uses MI to highlight diet failures and change talk for a new approach to eating and activity.

  pRactitioneR: What are you hoping to get out of our time together?

  client: I’m hoping you’ll help me lose weight. I’ve dieted a number of

  times and I always gain it back. I’m hoping you have a diet for me

  that I can actually stick to.

  pRactitioneR: You’re tired of the emotional roller coaster that often

  goes with dieting and want to find more reasonable changes that

 
you can stick to.

  The Complexities of Lifestyle Changes 19

  client: Yes. It would be nice if I lost a few pounds in the process, but I know as I get older, it’s my health that I want to maintain.

  pRactitioneR: While it used to be more about appearances, today

  your primary motivation for seeing me is to get healthier.

  client: Yes, exactly.

  pRactitioneR: Tell me a little more about your dieting experiences.

  client: Well, I did the no-carb thing, and that worked for a little bit, but I started really missing bread with my cheese. I’ve also tried

  counting points or calories, and I’m good about keeping track of

  that for a little while and then it becomes more than my busy life

  can handle. I’ve tried the diets where you buy all the foods ahead

  of time, but that doesn’t work for me now that I have a family.

  pRactitioneR: You’ve tried a number of diets and each one left you

  feeling deprived. What did you learn about yourself through those

  experiences?

  client: I learned that I will never be a supermodel.

  pRactitioneR: You’ve changed your expectations and your definition

  of health.

  client: Yes, I don’t need to lose a lot of weight to be happy.

  pRactitioneR: It sounds like you’d like your weight to take a back seat to your focus on health, but at the same time, your happiness is still

  somewhat dependent on your size. Tell me more about that part.

  client: Well, I guess that’s true, though I don’t like to admit it. I know when I was smaller, I felt better about myself. I liked the attention

  I would get from others whenever I lost weight. I felt like I was in

  really good shape and just had more energy in the day. I also liked

  that I could shop at the cute clothing stores. Now I do a lot of my

  shopping online. I used to love to shop.

  pRactitioneR: The high costs of cutting out foods you loved was