rounding food and fitness.
“Would it be all right if we talked more about your thoughts and
feelings surrounding food and activity today?”
Here’s an example of an opening script that demonstrates the start of
the engaging process. In this script an inpatient dietitian visits a patient who was recently diagnosed with congestive heart failure:
“Hi Jim, I’m Mike. I’m a dietitian here at the hospital. Your doctor
asked that we meet to talk about your new dietary needs to protect
your heart. I have about 15 minutes today to begin talking about that.
If our time today isn’t enough, I can return tomorrow, or we can sched-
ule an appointment for you to see our clinic dietitian the next time you visit your doctor. Would it be all right with you if we talked for a little bit about food and health? . . . Tell me a little about yourself and what you’re hoping to get out of our time together.” [The practitioner then
spends 2–3 minutes listening, finding out how the client is feeling, and uses core MI skills to convey an understanding of this.]
In just a few sentences, this dietitian has introduced himself, explained his role, and the time allotted. He has asked the client’s permission to discuss nutrition and has engaged him with a simple open-ended question.
Working at the beginning of the appointment to build rapport with the client is time well spent. The engaging process is like laying a foundation on which a house can be built. If great care is taken to make a strong, solid, smooth foundation, then there will be fewer problems with the house. In a well-laid MI foundation, there is a sense of trust between client and counselor. A weak foundation, laid in haste, could result in the client feeling judged or pressured to change, and shutting down without gaining anything from his time with you.
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THE FOUR PROCESSES OF MI
lIstenIng
When we honestly ask ourselves which person in our lives means the
most to us, we often find that it is those who, instead of giving much
advice, solutions, or cures, have chosen rather to share our pain and
touch our wounds with a gentle and tender hand.
—henRi noUWen
The key to building a strong foundation is to be a good listener. Ulti-
mately, engaging the client is not following a certain script or asking the client questions, but listening, really listening. Listen with your eyes, your body, and your words. Listen with delight and curiosity (see Figure 3.3).
Give the client your complete, undivided attention. An experienced counselor is able to maintain not only a physical presence, but an emotional presence. This is only possible when the counselor is able to put aside the mental to-do list and focus on the client.
A client feels heard when the counselor not only looks attentive, but
also provides verbal responses, or reflections, of what the client is saying.
We provide a more in-depth discussion of reflections in Chapter 8. At times, simple encouragers such as “Mmmm-hmmm,” or “I see,” or “Tell me
more” are all that are needed to engage the client. At other times, listening involves maintaining complete eye contact and presence, but also silence, allowing the client to express all that is on his mind. While extended silence may seem awkward, some clients may require more processing time. Experienced counselors are comfortable with silence. Moments when no one
is talking are moments in which the
We have two ears, two eyes, and
client has more time to process or to
one mouth, and when we use
respond. We have two ears, two eyes,
and one mouth, and when we use
them in that same ratio (80%
them in that same ratio (80% listen-
listening, 20% talking), clients
ing, 20% talking), clients feel heard
feel heard and respected.
and respected.
There are three benefits to being
a good listener. First, listening engages the client and builds trust, loyalty, and commitment in the relationship. Through paraphrasing or reflecting
what the client says in a genuine fashion, you will display empathy for the client’s situation. When a client feels heard, he is likely to share more personal information. By being a good listener, you can show you care.
Second, clients often experience emotional healing or reduced anxiety
about a behavior change just through talking about their concerns. When people feel heard, they want to talk more; they feel understood, respected, and accepted. There is something therapeutic about talking. You may, in fact, need to say very little at times for the client to reach his own resolutions. Third, through being a good listener, you will be able to better assess the situation and consequently provide better behavior change counseling.
Engaging and Focusing 51
Listen
with:
• Presence
• Undivided attention
• Eyes, ears, and heart
• Acceptance
• Curiosity
• Delight
• Silence
• Words
FIgure 3.3. Listening. Adapted with permission from MI training materials used by Steven M. Berg-Smith.
Listening is the greatest gift a counselor can give to a client. As Carl Rogers once said, “I don’t know what it is about listening. I just know when I’m heard, it feels damned good.”
reengAgIng
Even if you succeed in engaging a client at the beginning of a session, it’s possible to lose engagement later in the appointment. You may start to lose engagement if the client hears something that rubs him the wrong way or is not of interest. You may notice a shift in the client’s posture, eye contact, mood, or he will become quiet or agitated. When this happens, you can
re-engage him by simply checking in. The following practitioner statements can be used to draw the client back in:
“I get the feeling that I’ve said something that’s made you uncomfort-
able. What’s going on for you right now?”
“I can sense that you don’t like that suggestion I just made.”
“Let me check in with you. What are your thoughts and feelings about
what I just said?”
“I feel as though I might have lost you. Perhaps we need to back up or
switch gears. What are your thoughts?”
It may be tempting to ignore the fact that you and your client are
no longer on the same page. You could continue on in the conversation
pretending as if the connection was not lost, but if you do that, there is a chance the client may begin to tune out, or stop caring about the behavior change at hand.
Overall, engaging a client is about building a connection. This is
accomplished through asking the client specific questions about his or her
52
THE FOUR PROCESSES OF MI
initial hopes and expectations for a session and then listening with your whole body, while demonstrating components of the spirit of MI such as
empathy, compassion, and partnership.
FocusIng
Once the client is engaged, she can be guided to select a topic or behavior to focus on. Sometimes right away the client voices a behavior to change.
Other times the client knows she wants help changing her eating or activity patterns, but doesn’t know where to start. When this is the case, you can provide her with a list of possibilities, known as agenda mapping
(Miller & Rollnick, 2013). You and the client discuss possible topics and decide together which direction might be best. Typically, within this brief focusing conversation, you ask the client for topic ideas and also present a menu of options that you believe might apply to the client’s situation.
Once you have a map of various behavior change destina
tions, you can
discuss an agenda. Which topics might be useful to address first? Second?
Eventually?
When providing topic ideas, it’s important to offer the right number
of options. Too many choices, and the client could become overwhelmed.
Too few, and she could feel forced into a behavior change that she is not interested in.
It can be helpful to use a visual aide as you discuss possible topics.
Stott and colleagues used this method in their diabetes education (Stott, Rollnick, Rees, & Pill, 1995). Circle charts, also known as bubble sheets, were used to introduce possible topics (see Handout 3.1). A circle chart is simply a piece of paper with several circles, each with a different topic.
Circle charts are preferred over lists because topics are not provided in any order, and therefore no one topic is seen as more important or necessary than another.
Clients like to have options. A well-made circle chart includes at least one blank circle for the client to write in a topic that is not present. In addition, it is important to give clients an out. While showing the client the circle chart, ask him, “Which, if any, of these topics interest you?” By using the words “if any,” you give the client freedom to express a lack of interest in making a change, or to present a new topic.
You can introduce circle charts with an informal question—for exam-
ple, “Would you like to see a list of topics that I have discussed with some of my other clients? Which, if any, of these topics interest you?”
You may find it useful to have a variety of circle charts for various
disease states or conditions. A client who is being seen by a child feeding expert may select a topic from a circle chart that is designed for parents or parents-to-be, with circles on such topics as:
Handout 3.1
CIRClE ChaRt FoR NutRItIoN aND FItNESS CouNSElINg
Adding smal
Eating more
bouts of
regularly
activity
throughout the
throughout the
day
Adding
day
structured
exercise to the
week
Planning
Being more
satisfying,
mindful
balanced meals
while eating
at home
Other: ________
Tuning in to
hunger and
Beverages
fullness
Choosing
satisfying,
balanced meals
when eating out
From Motivational Interviewing in Nutrition and Fitness by Dawn Clifford and Laura Curtis. Copyright © 2016 The Guilford Press. Permission to photocopy this handout is granted to purchasers of this book for personal use or use with individual clients (see copyright page for details). Purchasers can download a larger version of this handout (see the box at the end of the table of contents).
53
54
THE FOUR PROCESSES OF MI
1. Picky eaters
2. Overeating
3. Undereating
4. Planning meals and snacks
5. Managing child behavior at the table
6. Breastfeeding/weaning
7. Baby’s first foods
Once the client selects a topic, or suggests an alternative topic, reflect the choice. Follow up the reflection with an open-ended question to find out more about why the client has selected that particular behavior—for example, “You’re concerned your daughter isn’t eating enough and you’d
like to discuss strategies for increasing her intake. Tell me more about your choice.”
Nutrition and fitness professionals are notorious for trying to cover
too many topics in one session. Making a single behavior change can be
quite a task. It’s best to tackle one topic at a time and work through motivations and barriers for that single topic. It’s better if the client is confident in making one change than less confident in making several changes at
once. Each behavior change success
It’s better if the client is confident increases client confidence in reachin making one change than less
ing future health goals. You can pull
out the circle chart again in future
confident in making several
sessions as the client masters a behav-
changes at once.
ior change and feels ready to attempt
new changes.
FocusIng styles
When assessing the client, it may become clear which behavior change
would benefit the client most, which would align with the nutrition diagnosis step of the NCP. If the practitioner chooses the focus of the session, then it is considered a counselor-directed session.
However, when incorporating motivational interviewing into the ses-
sion, the client might be asked to choose the nutritional problem he or she would like to work on, thereby making the nutritional diagnosis and intervention client driven. With permission, the practitioner would share her opinion about which change or changes will most likely result in the outcomes the client desires. Sometimes the client selects a behavior change that lines up with the nutrition-related problem that the practitioner feels is most important. However, this is not always the case.
Let’s say that following the assessment, the nutrition practitioner is
convinced that the most important nutritional problem for a client with
Engaging and Focusing 55
hypertension is his low intake of potassium-rich foods (as evidenced by low serum potassium and the dietary recall). After asking permission, she tells the client that increasing intake of potassium-rich fruits and vegetables is the most effective way to address his blood pressure and provides an additional list of other possible behaviors on which to focus for lowering blood pressure, such as physical activity and reducing dietary sodium. What if the client has no interest in adding potassium-rich foods, but instead is interested in increasing physical activity? What should the practitioner do?
Explain the importance of the practitioner-selected nutritional diagnosis (inadequate intake of potassium), or head in the direction selected by the client? Hang on to that question for a minute while you consider the following.
There are three styles in determining the focus and therefore the pri-
mary nutritional diagnosis addressed in the session: directing, following, and guiding. If the practitioner uses a directing style, then the practitioner decides on the focus of the session and doesn’t ask for the client’s input.
Directing would sound like this:
“As I mentioned, your blood potassium levels are low, which is likely a result of the diuretic you’re taking. It’s important to get your potassium levels back up. In addition, eating potassium-rich fruits and vegetables may help lower your blood pressure. Let’s talk about that today.”
If the practitioner uses a following style, then the practitioner gives the client full rein in selecting the focus, as in the following example:
pRactitioneR: Now that I’ve explained the different changes that
clients with high blood pressure often make, which one, if any,
sounds most appealing to you right now?
client: I’ve been wanting to start exercising again, so I think I’d like to start with that one.
pRactitioneR: Great. What ideas do you have?
If the practitioner uses a guiding style, then both parties are involved in discussing and deciding upon the focus. Guiding would sound like this: pRactitioneR: Now that I’ve explained the different changes that clients with high blood pressure often make, which one sounds most
appealing to you right now?
client: I’ve been wanting to start exercising again, so I think I’d like to start with that one.
We can certainly explore that some more. May I share my thoughts
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THE FOUR PROCESSES OF MI
about how your recent lab tests might help us choose the most
effective things to do?
client: Sure.
pRactitioneR: The lab tests here are telling me your blood potassium
levels are low. Adding high-potassium foods into your diet would
bring these values up and help your blood pressure. What is your
response to this?
client: Yes, that concerns me too. It would be good to talk about that
also. I know bananas are high in potassium, but I’m sure there are
other foods you could tell me about.
pRactitioneR: Yes, I have a list here we can look at if you’re inter-
ested. Perhaps we could start today’s session by talking about
your plans for exercise and then before you leave we can revisit
potassium. How does that sound?
Guiding is a collaborative approach that acknowledges that the cli-
ent’s agenda and the practitioner’s expertise are both important. This
method best aligns with MI while still addressing the nutrition diagnosis that becomes apparent in the nutrition assessment. By giving the client the option to select the focus of the session, you maintain a spirit of autonomy and choice, which may increase the client’s reception to discussing other topics in the future. In addition, if the client starts by making a change he is confident he can make, this confidence may help him succeed when he
attempts other health-related behavior changes.
reFocusIng
On occasion, the conversation may begin drifting away from the topic of the behavior change. When this happens, you may need to reengage the client and help to refocus the conversation. In the following script, notice how the practitioner brings the client back by bringing up the original focus and then asking an open-ended question. There’s more on open-ended questions in Chapter 6.
pRactitioneR: You picked “meal planning” on the circle chart as
a topic you’d like to address in this appointment. Tell me more
about why you selected that topic.
Motivational Interviewing in Nutrition and Fitness Page 8
