fourth process, planning, which is discussing the “how to” of change. The client is invited to develop a plan of action and set specific, realistic goals to initiate a behavior change. In the spirit of MI and autonomy, the client leads this process. The practitioner asks the client how he or she might go about making the desired change and then is there to provide ideas, should the client need support.
The four processes are meant to provide structure and framing. They
do not necessarily progress linearly, but do build on one another (see Figure 3.1). In ballroom dancing, a couple will cover different areas of the dance floor at different times during the dance. In MI, the practitioner and client work in much the same way. In addition, it is not necessary to work through each process in a single session, or even to progress in an exact order. For example, the counselor might begin by engaging the client and then invite her to focus on a specific topic. The counselor may ask the client evoking questions to elicit motivations for change. During the evoking process, the counselor may discover that the client is not particularly interested in making the behavior change originally selected and consequently they decide together to select a different focus.
In some appointments, the counselor and client may never discuss
planning, especially if the client hasn’t yet expressed readiness to change. In other sessions, the counselor and client may progress through evoking and planning and then decide to return to the focusing process when the client
Engaging and Focusing 43
Planning
Evoking
Focusing
Engaging
Engaging
Focusing
Evoking
Planning
• Give a warm,
• Invite the client to
• Identify and
• Ask permission
friendly greeting.
select a topic to
respond to
before giving
• Make
discuss.
ambivalence.
information.
introductions.
• Present topic
• Evoke change
• Offer information
• Ask rapport-
ideas to the client
talk.
using elicit–
building
if the client is
• Assess readiness
provide–elicit.
questions.
unsure.
to change.
• Offer a concern.
• Establish time
• Find out the
• Transition to
• Invite client to set
available to meet.
reason behind
planning process.
goals
• Give an overview
topic selection.
• Assess barriers to
of what to expect.
change.
• Determine the
reason for the
visit.
FIgure 3.1. The four processes of MI. Based on Miller and Rollnick (2013).
selects a second behavior to change.
Ultimately, the progression through Ultimately, the progression
the four processes depends on the cli-
through the four processes
ent’s motivation to change, which is depends on the client’s
fluid.
motivation to change, which is
The following brief MI session fluid.
includes all four processes. In this
example, the client is eager to make a specific behavior change. The counselor is able to guide the client through all four processes of the MI appointment, even with limited time.
Engaging
pRactitioneR: Welcome, Annie. Glad you could make it. My name’s
Sue, and I’m a nutritionist. I was asked by your chiropractor to
spend just 15–20 minutes with you today to discuss any nutrition
topic that interests you. Before we get started, tell me a little about yourself.
client: Well, I’m 38 years old, live alone, and work at a local software company.
pRactitioneR: So you work with computers. How do you like your
job?
44
THE FOUR PROCESSES OF MI
client: I’ve been there for about 8 years, and the job definitely has its perks. It’s boring at times, but overall I enjoy the people I work
with.
pRactitioneR: It sounds like there are parts of it you enjoy, especially the people you work with. That’s great!
pRactitioneR: Before we get started, how did you feel about coming
down to my office today?
client: Oh, not too bad. I wasn’t sure what to expect; I’ve never met
with a nutritionist before, but I saw your advertisement at my chi-
ropractor’s office and I thought I could really benefit from talking
to someone.
pRactitioneR: You’re feeling like there might be some areas you
could work on when it comes to your eating patterns and you’re
hoping I can help.
client: Yes. I mean, there’s all this stuff on the Internet, but it’s hard to figure out what is right. Plus, I thought meeting with someone
would help me actually find the motivation.
pRactitioneR: You’re hoping that having someone to bounce ideas
off of might help you make some changes to your diet.
client: Yes, it’s nice to have some support.
pRactitioneR: You’re not completely sure what to expect, but you
know you’d like some support as you attempt to make some
changes that improve your health. I’d like to know a little more
about the changes you’re interested in making.
Focusing
pRactitioneR: I have a chart here with seven different health topics
we could discuss today and an empty circle in case there’s some-
thing else that you’d like to discuss that’s not on here. How do you
feel about looking this over and deciding on a topic?
client: That would be fine. I was thinking on the way over here that
it would be helpful to have someone to hold me accountable for
this one change I’ve been meaning to make.
pRactitioneR: Oh yeah? What’s that?
client: I’d like to drink more water throughout the day.
Evoking
pRactitioneR: You’d like to stay better hydrated. Tell me more about
why you picked drinking more water as a change to work on.
Engaging and Focusing 45
client: Well, I drink a few sodas each week, coffee, and a little juice, but I was realizing the other day that I hardly ever drink water.
I was reading a magazine article at the chiropractor’s office the
other day and it said that a lot of times people think they are hun-
gry, but really they are just thirsty. I think I eat sometimes because
I think I’m hungry, but I’m really just dehydrated.
pRactitioneR: You’re interested in drinking more water because you
may be mistaking hunger for thirst.
client: Yes, exactly.
pRactitioneR: What else motivates you to drink more water?
client: I’ve been feeling a cold coming on and I wonder if I drink
more water if I would be able to fight off the cold better. Plus I’ve
been feeling really run down lately; maybe I’m just dehydrated.
pRactitioneR: You have a few different motivations for making this
change. You mentioned that drinking more water might give you
more energy, keep you from getting sick, and maybe even make
you feel fuller. On a scale from 0 to 10, with 0 being unint
erested
and 10 being very interested, how interested are you in making
this change?
client: I’d say I’m at about a 7 or an 8.
pRactitioneR: A 7 or an 8 suggests you’re pretty motivated to make
this change. What led you to choose that number?
client: I’m really feeling like this change could benefit my health.
However, I’m not quite sure how I’m going to go about actually
adding more water to my day. Plus, I get bored with the taste of
water, so it’s hard to stay motivated to drink more.
pRactitioneR: You have mixed feelings about making this change.
On the one hand, you’re concerned that adding more water
might be a bit of a challenge, especially given that you aren’t
crazy about the taste and, on the other hand, you recognize how
drinking more water might really help you stay well and have
more energy.
client: Yes! It seems like a good change to make, but I know it won’t
be easy.
Planning
pRactitioneR: You’re willing to give it a try. What ideas do you have
for increasing your water each day and making it taste good?
client: I have a water bottle, but I don’t feel like grabbing it in the morning and filling it up. I think if I filled the bottle the night
46
THE FOUR PROCESSES OF MI
before and it already had cold water in it, I might be more inclined
to take it with me when I go to work in the morning.
pRactitioneR: So filling it up the night before might motivate you to
be more consistent with your water bottle. What else?
client: I know if I just had it with me in the car and at work, I’d drink more water.
pRactitioneR: You’re pretty confident that if you had the water bot-
tle with you in the morning, you would drink from it throughout
the day. Would you like to hear another strategy that has worked
for some of my clients?
client: Sure!
pRactitioneR: Some have found that if they add flavoring to their
water like lemons or a little juice, they are more likely to drink
from their water bottles. You will be the best judge of whether
something like this works for you. What are your thoughts?
client: Oh yes, I can see how that would help. I think the key is just
remembering to get it all ready the night before. Maybe I can add
fruit or juice to my water bottle and stick it in the fridge, and then
I just need to remember to grab it in the morning.
pRactitioneR: You’ve figured out a strategy that could work. What
ideas do you have for reminders to grab your water out of the
fridge in the morning?
client: Maybe if I just put a sign on the door out to the garage, I’ll
remember.
pRactitioneR: Great idea! It sounds like you’re excited to make this
change. You’ve thought through the different ways this change
might benefit your health and you have some strategies in mind
for following through with your plan.
In this short script, the counselor leads the client across all areas of the dance floor, from the initial engaging interaction all the way to developing an action plan. However, it’s the client who is coming up with the behavior change and plans for execution of the change. The counselor is simply inviting the client to consider motivators and barriers for making the change.
This is a simplistic example, and in nutrition and fitness counseling, clients and conversations can be much more complicated. Remember that while
the four processes provide a framework, because we’re discussing human
behavior, they cannot become formulaic. Ultimately, the processes and
sequence of the appointment will largely depend on the client’s needs.
The client’s needs are assessed throughout the session. In many ways,
the engage, focus, evoke, and plan of MI parallel the assessment, diagnosis,
Engaging and Focusing 47
intervention, and monitor/evaluation of the Nutrition Care Process (NCP), which is highlighted in Figure 3.2. Similar to the NCP, in which assessment of the client guides the intervention, the engaging, focusing, and evoking steps lay the foundation and direction for the planning process. Traditionally, the practitioner has led the focusing process (nutrition diagnosis) of the appointment and provided strategies for making the behavior change.
Alternatively, when using MI the client takes the lead on selecting a topic to focus on and is given the opportunity to come up with ways to make this change fit easily within his or her day-to-day schedule. The practitioner is there to help if the client runs out of ideas.
We will now go into more detail about implementing these four
NCP
MI Process
Examples
Assessment
Preappointment
• Practitioner reads medical chart.
Engage
• Practitioner conducts an oral assessment.
Focus
• Practitioner asks the client to complete an
assessment questionnaire prior to the first
visit.
• Practitioner asks the client the reason for the
visit.
• Practitioner asks the client what he/she is
hoping to get out of the session.
Diagnosis
Focus
• Practitioner asks client what changes, if any,
he/she is interested in discussing further.
• Practitioner shares possible topics to discuss
based on assessment results.
• Practitioner shares reason for consult, if
unknown to the client.
Intervention
Evoking
• Practitioner invites the client to voice
Planning
motivations for behavior change.
• Practitioner invites the client to determine a
successful route toward change.
• Practitioner guides the client to devise
solutions for barriers to change.
• Client determines specific goals for change.
Monitor/
Planning
• Practitioner invites the client to determine
evaluation
Postappointment
appropriate monitoring methods related to
behavior change.
• Practitioner and client discuss plans for
follow-up.
• Practitioner reviews any new lab values
available.
FIgure 3.2. MI and the NCP.
48
THE FOUR PROCESSES OF MI
processes of MI, beginning with engaging and focusing in this chapter and evoking and planning in Chapters 4 and 5.
engAgIng
It only takes about 3 seconds to make conclusions about a person we meet for the first time. In that short time we have a sense of whether the person can be trusted. What are qualities you look for in a potential friend, mentor, partner, or therapist in those first few seconds? A warm smile? Eye contact? A calming voice? Those initial qualities begin the engaging process.
The term engage means “to induce to participate” ( www.merriam-webster.com/dictionary/engage). The goal of the engaging process is to establish a helpful connection. The first few minutes of an initial appointment or interaction serve as a foundation for all remaining interactions.
Whether it’s an initial phone call, or a warm, friendly greeting in the waiting room, those first exchanges set the tone for the rest of the session. As the counselor, you will send the client messages through words and body language, initiating the engaging process
.
Clients can be engaged through both nonverbal and verbal communi-
cation. Nonverbal qualities to be aware of as a counselor include:
• Body posture. Maintain an open, relaxed posture, facing the client and leaning slightly forward to show you’re paying attention.
• Head nods. Occasional head nods demonstrate agreement and
encourage the client to continue to communicate. Excessive head
nods can be distracting and can make you appear anxious or impa-
tient.
• Facial expressions. It’s important to appear natural, relaxed, and content. Be mindful of your emotional state; it’s often exhibited
through facial expressions. Some counselors find meditation and
deep breathing exercises to be useful in centering oneself before a
session.
• Eye contact. Comfort with eye contact varies between cultures. In Western cultures, maintaining eye contact demonstrates interest.
• Voice. Consider pitch, volume, tone, and speech clarity. Adopt a voice tone that is audible and clear, but not harsh or distracting.
What you verbally communicate to the client at the beginning of the
appointment is also important in developing a counseling environment.
The following are topics that could be included in the first few minutes of a session:
• Introduce yourself and inform the client of your role.
“My name is Cheri and I’m a dietitian here at the clinic.”
Engaging and Focusing 49
• Use open-ended questions to draw the client into a conversation.
“Tell me a little about yourself.”
“What brings you in today?”
• Let the client know how much time you have for the session.
“We have 30 minutes today to discuss your health habits.”
• Give the client an overview of what to expect in the session.
“I like to start out each session getting to know my client’s eating
and activity patterns. Then we can discuss how you feel about
your current patterns and whether or not you’re interested in
making any changes. If you are interested in making a change,
then we can discuss how you might set a specific goal for your-
self.”
• Ask permission to explore the client’s thoughts and feelings sur-
Motivational Interviewing in Nutrition and Fitness Page 7
