Motivational Interviewing in Nutrition and Fitness
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worth it to you, at least in the short term, because of how being
thinner made you feel.
client: Well, it was always worth it at first. But then it felt like my body became a sponge and every time I slipped up, my body
would just absorb those calories and it seemed impossible to keep
the weight off. And then as the weight would come back on, I’d
start to feel embarrassed and wondered what people would think.
pRactitioneR: It felt like an uphill battle with everyone watching.
client: Exactly! I’m sure they weren’t watching, but they had to have
noticed as my wardrobes would change with each new inch in my
waist.
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MI BASICS
pRactitioneR: It sounds like the ups and downs of dieting are what
you truly hope to avoid. You want to learn to love and accept your
body and at the same time discover ways to eat and exercise so
that you feel fit, healthy, and energized. Would you be willing to
explore these ideas a little more with me today?
client: Yes!
At the beginning of the dialogue, the client didn’t sound ambivalent.
She was set on her goal to lose weight. However, with some active listening and evoking questions from the practitioner, the client began to realize that what’s most important to her is an overall feeling of health and fitness. She began to realize that previous attempts at the “quick fix” backfired and she became receptive to taking a different approach toward adopting more sustainable lifestyle changes.
FroM AMBIvAlence to ActIon: the PrActItIoner’s role
Ambivalence is a fork in the road. Will the client choose to make the
change, or keep things the same? The direction your client takes depends mostly on your style and guidance as the practitioner. In a state of ambivalence your client becomes conflicted and may feel a little embarrassed about having this discrepancy pointed out. In this delicate state of mind, she or he becomes highly responsive to the practitioner’s communication style. A misstep can throw your client into a reactive stance and voicing sustain talk, that is, talk that favors the status quo. In the excerpt below, the client voices ambivalence about meal planning and preparation. The
practitioner responds by trying to identify and fix the problem. Notice how this response leads the client to argue for the status quo. In doing this, the practitioner has essentially blocked the client from considering the change.
client: I hate cooking and especially doing dishes. I definitely do not have time for that. Plus, I’m a terrible cook. But I’m really tired of
eating out all the time and it’s so expensive.
pRactitioneR: [ not using MI] You need to make time. This is important.
client: I know, but we don’t get finished with dinner until 8 o’clock
already.
A misstep like the one above can easily derail a client’s movement
toward change. There are key strategies that you can use to help your
clients move through ambivalence using a gentle, guiding manner. These
strategies are dispersed throughout this book, but below is a glimpse of the
The Complexities of Lifestyle Changes 21
most important factors in a practitioner’s communication style that directly influence client ambivalence.
taming the righting reflex
Most likely, you got into this line of work because you wanted to help
people live healthier and happier lives. You are probably the type of person who cares for the people around you and wants to help others. This is a wonderful quality and one that makes you an empathetic and understanding practitioner. You also have an understanding of complex health topics that many people do not, and you’re probably eager to share that knowledge with others. Our first inclination as nutrition and fitness practitioners when we hear a client’s ambivalence is to start to nudge him or her forward by throwing out simple strategies for change. Does this sound familiar?
client: I get home after work and I’m exhausted. I know I need to
take a walk around the block, but it takes all of my energy just to
get out of my work clothes and start making dinner.
pRactitioneR: [ not using MI] What if you stopped at the gym before getting home? Sometimes you have to change your routine a little
and you find that you have more energy.
client: Maybe. I don’t know. It’s so crowded right after work.
Here’s another example of a nutrition counselor reacting to ambiva-
lence by giving unsolicited advice.
client: My main problem is my snacking. My girlfriends and I get
together twice a week to play cards and that’s where I do a lot of
my snacking. There’s always a bowl of candy on the table while
we play. I wouldn’t eat it if it weren’t right in front of me the whole time. They should know better than to serve that kind of stuff.
Half of us are diabetic.
pRactitioneR: [ not using MI] What if you brought your own snack?
Here’s a list of diabetic snacks that are quick and easy; perfect for
a card table.
client: Oh, I don’t think so. You don’t get between these ladies and
their sweets.
As experts in nutrition and fitness, it can be difficult to restrain yourself from giving unsolicited advice when you see your clients struggling with ambivalence. This type of advice giving is also known as the righting reflex. The following sentence starters are all predictors that you’re about to use the righting reflex.
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MI BASICS
“Why don’t you just . . . ?”
“Hey, what about trying . . . ?”
“What you need to do is. . . . ”
The righting reflex reflects a directive counseling style that includes giving advice or tips without gaining permission from the client. In the process of change, unsolicited advice becomes a roadblock that can interfere with the client’s progression toward change. When a roadblock goes up, the client has to take a detour and think about how to respond to your advice, taking the focus off of strategizing a change. Use of the righting reflex may even stall out the client–practitioner relationship before it has a chance to get going. Although you have the best intentions, the way you go about giving advice and offering information is as important, if not more important, than the information itself.
People often consider the advice or recommendations of those they
respect and trust. Using MI techniques helps you to gain respect and trust from your clients by treating them with unconditional positive regard, a concept first pioneered by the psychologist Carl Rogers (Rogers, 1995).
Rogers believed that people have
By adopting an attitude of
the resources within to bring about
unconditional positivity toward
personal growth. By adopting an
people trying to change, you allow attitude of unconditional positivity them the support they need to take toward people trying to change, you allow them the support they need to
responsibility for their behaviors
take responsibility for their behaviors
and accept themselves as they are.
and accept themselves as they are.
Putting the client in the driver’s seat
The righting reflex is just one way practitioners may inadvertently increase sustain talk when a client is ambivalent about change. An underlying power struggle often results when you use a directive communication style. At the end of the day, people end up doing what they choose to do. By honoring the client’s control, or autonomy, you can avoid a power struggle and your counseling appointments will be more productive. This isn’t to say that the client leads and you follow. MI is a guiding technique; you come alongside the client as a kno
wledgeable aide in the behavior change process. Honoring your client’s autonomy tells him that he’s in charge and you respect him from the minute he walks through the door. Defensiveness often melts away as your client feels supported.
trying on the client’s shoes
You won’t always be able to relate to your client’s experiences; it’s generally impossible to actually walk a mile in another person’s shoes. However, a
The Complexities of Lifestyle Changes 23
key factor in assisting your client in navigating the maze of ambivalence is empathy. Empathy is defined as “the feeling that you understand and share another person’s experiences and emotions” ( www.merriam-webster.com/
dictionary/empathy). Note that empathy does not involve you actually going through another person’s experiences and emotions but instead feeling that you understand the experiences and emotions.
Empathy is essential in cultivating healthy human relationships. The
key to developing empathy is being a good listener. Plus it takes a little bit of curiosity and imagination to understand what the client may be going through. It’s normal to have mixed feelings about change. That’s why it’s important to set aside your personal agenda and attempt to understand
your client’s feelings of internal conflict.
Below are two dialogues. In the first, you can see the result of a counseling session in which the cardiac rehabilitation dietitian seems to lack empathy. In the second, you will notice the power of empathy in moving
the client forward along the stages of change. Practitioner statements that directly express empathy are italicized.
Scenario 1
pRactitioneR: Welcome to cardiac rehab. I’m the dietitian here and I
see on your chart that you had a heart attack 3 weeks ago.
client: Yes, that’s right.
pRactitioneR: What questions do you have about what you should
be eating?
client: I think I’m supposed to be watching how much fat I eat, right?
My wife stopped cooking with butter years ago, so that won’t be
a problem.
pRactitioneR: It’s not just about what you need to cut out. It’s also
about what’s missing. You’ll also want to add foods like fruits,
vegetables, legumes, and nuts, as well as be more physically active.
Here, I have this handout for you to take home that explains more
about these topics. I suggest you show this to your wife when you
get home.
client: OK.
Scenario 2
pRactitioneR: Welcome to cardiac rehab. I’m the dietitian here and
I see on your chart that you had a heart attack 3 weeks ago. That
must have been really scary.
client: Yes, it really freaked me out. I feel pretty lucky that we caught it early enough.
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MI BASICS
pRactitioneR: You are relieved to have come through it all. I know
you met with a dietitian briefly while you were in the hospital.
Have any questions come up for you since then? I know it can
be overwhelming in the hospital when you’re interacting with so
many different people.
client: Yes, my hospital stay was a whirlwind. And I only remember
about half of it. It hasn’t been too hard. We hadn’t been cooking
with butter for years, so we didn’t really need to make any major
changes.
pRactitioneR: Glad to hear it hasn’t been too challenging. I have a list of different topics here that we could discuss today, if you’re
interested. Are there any topics here that you’d like to go over?
client: Yes, we should probably talk about eating more fruits and
vegetables. I’m sure there’s more we could be doing there.
pRactitioneR: Great. Let’s do that. I have a list here of some ways
to add more fruits and vegetables to meals and snacks, which you
can take home to your wife, if you think she’d be interested, but
first, tell me what you’ve already tried.
In the second scenario, the dietitian displays empathy and provides the client with a sense of autonomy. The client is in the driver’s seat and the practitioner is demonstrating a desire to understand the client’s perspective. The second scenario is slightly longer; it may take a little more time and patience in your interactions with clients to express these attributes.
However, the payoff is extraordinary, as the client is much more likely to attempt and maintain a behavior change with this approach and return for follow-up visits.
Clients struggle when making changes to their eating and physical
activity habits for a variety of reasons. In this chapter we’ve only scratched the surface of the complexities of behavior change. These useful techniques for assisting clients through ambivalence are revisited in great detail throughout the remaining chapters.
It is common to witness clients adopting unrealistic expectations for
themselves, thinking they must do it perfectly or not at all. At times, they will get stuck, favoring to sustain the status quo until faced with significant negative outcomes.
As the practitioner, your communication style significantly influences
your clients’ decisions to make and maintain lifestyle changes. You not only influence what they decide to change but also if they will decide to change.
By identifying ambivalence and helping your clients consider the discrepancies between their actions and values in a nonjudgmental and empathetic manner, they can successfully move forward through ambivalence and
eventually achieve their health goals.
chAPter 2
The Spirit of Motivational Interviewing
People don’t care how much you know until they know
how much you care.
—John hanley
Doing motivational interviewing with someone is like
entering their home. One should enter with respect,
interest, and kindness, affirm what is good, and refrain
from providing unsolicited advice about how to arrange
the furniture.
—kamilla VenneR
As a practitioner, you will not physically be with your clients when they act on health decisions. You won’t be there when they are at the grocery store or when they get off work and decide whether or not to go for that walk you talked about. You, in effect, have absolutely no control over your clients’ behaviors. They have the right to make decisions that do not support their health. What they need from you is not a wagging finger or a repri-mand; they need to be affirmed of their positive potential. Understanding this will help you to take your rightful place in the counseling relationship, not as a judge of their behavior, but as a guide to help them reach their health goals. This chapter describes the most fundamental component of
MI: your mindset.
The mindset or underlying spirit of MI affects every aspect of how
you interact with a client, including verbal and nonverbal communication.
Miller and Rollnick (2013) have framed the spirit of MI using four key
concepts: partnership, acceptance, compassion, and evocation, which are summarized in Figure 2.1.
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MI BASICS
Spirit of MI
Definition
Examples of practitioner statements
component
Partnership
The practitioner functions
“You’d like ideas for high protein foods. If
as a partner or companion, you think it might help, we could make a
col aborating with the
list of protein-rich foods you already eat
client’s own expertise.
and then together we can brainstorm others
you’d be interested in
trying.”
Acceptance
The practitioner
“You seem frustrated. On the one hand,
communicates absolute
you’d like to be more consistent about
worth, accurate empathy,
going to the gym, and, on the other hand,
affirmation, and autonomy
you don’t enjoy working out on the fitness
support.
equipment there. There are times in your life
when you’ve been very committed to going
and you’re realizing that the gym has lost its
appeal. What do you think you’ll do?”
Absolute
The practitioner emphasizes “I real y appreciate you sharing how you feel worth
the inherent value and
about your body right now. These feelings
potential of every human
are important, and I’m honored that you felt
being.
you could trust me with the information.”
Accurate
The practitioner perceives
“You hope that I’m going to give you
empathy
and reflects back the
information that will help you manage your
client’s meaning.
blood sugars and at the same time, you’re
a little worried that you’re going to have to
give up certain foods that give you immense
pleasure.”
Autonomy
The practitioner accepts
“It’s your body and you know yourself better
and confirms the client’s
than anyone else. Ultimately you get to
irrevocable right to self-
decide which foods your body does best
determination and choice.
with.”
Affirmation
The practitioner
“You are a fighter. You don’t let anything
accentuates the positive,
stand in your way of accomplishing your
seeking and acknowledging goals.”
a person’s strengths and
efforts.
Compassion
The practitioner acts
“I am so sorry to hear that you and your
benevolently to promote
family are going through this financial
the client’s welfare, giving
hardship. If you’re interested, I’d be happy