changing my diet before he puts me on those drugs to lower my
cholesterol. ( Voice tone sounds unenthusiastic.)
pRactitioneR: OK, so you’re here because your doctor referred you
for help lowering your cholesterol through diet and exercise.
[reflection] How do you feel about being here? [open-ended ques-
tion]
client: I don’t know. He doesn’t know that I already tried making
changes a year ago when I was with my last doctor and it was
impossible.
pRactitioneR: You tried making changes on your own; you obvi-
ously care about your health. [affirmation] Tell me more about
that. [open-ended question]
client: Yeah, it’s not like I want a heart attack or anything. I just don’t have time to eat all perfect, so I wish he’d just give me those
drugs already.
pRactitioneR: You’re aware of the risks of high cholesterol and hav-
ing a heart attack is one risk that concerns you. [reflection]
client: Yeah, I would like to stick around a little longer. I’m good at popping pills. It’s the whole cooking thing that gets me. Plus, I like food, and I like to eat and you’re just going to tell me to stop
eating, or something.
pRactitioneR: You’re someone who is consistent when it comes to
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THE FOUR PROCESSES OF MI
taking medication, so you feel that might be your most viable
option at this point. You’re concerned that making changes to
lower your cholesterol would involve having to eliminate foods
you like. You seem to care about your health and want to improve
your cholesterol. I appreciate your honesty in sharing some reser-
vations you had about seeing me today. Some of my clients have
found that by making a few small changes, they’ve been able to
lower their cholesterol without having to revamp their entire diets.
Even making a few small changes can be hard, though. Ultimately,
it’s your choice what you’d like to do. [summary]
Focusing
pRactitioneR: We have about 30 minutes to spend together today
and I’m wondering how I can best help you. [open-ended question]
client: You can help me by telling my doctor just to give me those
pills!
pRactitioneR: I’d be happy to talk to your doctor about that. How
else can I help? [open-ended question]
client: I don’t know. I eat out a lot, and I can’t really cook all that great, so maybe just tell me what foods I can order, or something.
pRactitioneR: What’s most feasible for you right now is to maybe
make a few changes in the foods you order when you eat out.
[reflection] You’ve come up with a change that feels doable to you.
[affirmation] Tell me more about the foods you like to order at a
restaurant. What are your favorites? [open-ended question]
client: I like a good burger and French fries. I also get burritos from the Mexican restaurant near my work. Now and then I hit up a
sandwich shop, and I get pizza and beer with the guys on Friday
nights. Oh, and I just started going to this new BBQ place a few
blocks from my apartment where the ribs are something else! I
just start salivating when I think about them.
pRactitioneR: You have many restaurant favorites. [reflection] Before
we start talking about finding a few small changes in what you
order to lower your cholesterol, can we talk for a moment about
your health concerns? [asking permission]
client: Yeah, that’s fine.
Evoking
pRactitioneR: You mentioned earlier that you don’t want to have a
heart attack. [summary] What else motivates you to make choices
Evoking 67
that support your health right now? [open-ended question to
evoke more change talk]
client: I have this new girlfriend who’s pretty special. We really have a good time together. And things are just getting good, so I don’t
want to die on her.
pRactitioneR: There’s someone special in your life who might miss
you. [reflection of change talk]
client: Yeah, she wanted to come today, but had to be somewhere
else. When I told her about this cholesterol stuff, she was like,
“You’re stubborn as hell; I don’t know how that dietitian is going
to get you to do anything with your diet.” She knows me pretty
well, doesn’t she?
pRactitioneR: It’s nice when the people we care about “get” us.
[affirmation] I’m not really interested in talking you into doing
anything you don’t want to do. It’s your health and your body,
and you get to decide how you want to treat it. I’m just here if you
want help. [demonstration of autonomy]
client: Yeah, it can’t hurt to make a few changes, as long as I still get to eat my ribs.
pRactitioneR: Yes, let’s be sure to keep those as part of your diet.
They sound pretty important to you. [reflection]
client: They’d be important to you too if you had tried them.
pRactitioneR: I’ll have to be sure and do that. What else motivates
you to want to treat your body right? [open-ended question to
evoke change talk]
client: I’ve seen some close friends go through the wringer lately
in terms of their health. I don’t want the last few decades to be
a miserable existence. I want to get out and do things when I
retire.
pRactitioneR: You’d like to stay active in your older years, and you
believe taking care of yourself now might pay off later. [reflection
of change talk]
client: Yes, plus these doctors’ visits cost a fortune and that’s one fortune I won’t have as I get older.
pRactitioneR: Cost of medical bills if your health declines also moti-
vates you to stay healthy. [reflection of change talk]
client: Yeah, I have a hard enough time as it is making my bills each
month; I don’t need medical debt.
pRactitioneR: Thank you for explaining what motivates you to
change. [affirmation] You mentioned that being healthy and active
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THE FOUR PROCESSES OF MI
for your girlfriend are important, as well as cost. [summary] What
else? [open-ended question to evoke change talk]
client: Can’t think of anything. I lead a pretty simple life.
pRactitioneR: At this point, how important is it to you to make some
small changes in your ordering habits when you eat out? [open-
ended question to assess readiness to change]
client: I’d say it’s pretty important. As long as I can treat myself to an occasional rib dinner, then it shouldn’t be too bad.
At the beginning of this dialogue, the client expresses significant
sustain talk and some change talk. The practitioner reflects the client’s ambivalence while also emphasizing his change talk. As a result, the client expresses more change talk. In addition, the practitioner strategically evokes more change talk by asking questions such as “What motivates you to take care of your health?” The practitioner does not push the client into making a change he isn’t interested in making. Instead, she promotes client choice in selecting a behavior change that feels doable.
PrePArIng For PlAnnIng
In the previous dialogue, the practitioner begins to hear significant change talk toward the end of the conversation and then asks how important the change is to th
e client. Assessing readiness is an important step before diving into the planning process. If
the client values the new behavior,
If the client values the new
then he is more likely to be ready to
behavior, then he is more likely to attempt the change.
be ready to attempt the change.
Another way to assess the cli-
ent’s readiness to change is to use a
scaling question. Scaling questions
invite clients to consider their level of interest or readiness to change on a scale from 0 to 10, with 10 meaning fully ready or interested and 0 meaning not at all ready or interested.
Here are some examples of scaling questions you can use to assess a
client’s readiness to change:
“On a scale from 0 to 10, with 0 being ‘not at all’ and 10 being ‘very,’
‘how important is this change to you?’
‘how confident are you that you can make this change?’
‘how interested are you in making this change at this time?’
‘how ready are you to make this change?’ ”
Evoking 69
In general, scaling questions that ask about interest or importance
occur more at the beginning of the appointment when discussing motiva-
tions for change, while a scaling question regarding confidence in making the change is typically asked more toward the end of the session after the planning has been discussed.
Once a scaling question is asked, follow-up questions are useful in
exploring reasons behind the answer. It is important to find out why the client selected a particular number to represent her readiness to change before moving forward.
The following script demonstrates how to use a scaling question to
assess readiness to change.
pRactitioneR: At this point you’ve shared some specific reasons why
you would like to bring your lunch to work more often, including
the fact that it will save you money and result in a lower-sodium
meal. And you’ve also expressed that it may be a bit challenging
at first to get the hang of putting that lunch together in the morn-
ing. [summary] I’m curious at this point, how interested are you
on a scale from 0 to 10 to begin bringing your lunch to work a
few times a week? 10 would mean that you are eager and ready
to make this change and 0 would mean that you’re really quite
hesitant. [scaling question]
client: I’m at about a 7 or an 8.
pRactitioneR: OK, a 7 or 8. So you’re somewhat ready to make this
change. [reflection] Tell me a little bit about your answer. Why not
a 6? Or why not higher, like a 9? [open-ended probing question]
client: Well, I’m fairly confident that I want to make this change. I
came up with the idea in the first place, so there’s a big part of me
that wants to give it a try. But I guess I’m not a 9 or a 10 because
we haven’t quite talked through how exactly it’s going to go or
what types of foods I will need to bring with me. So I’m a little
nervous about the unknown at this point. Plus, I know I’m going
to want to eat out with my coworkers whenever I’m invited to. So
I can see how that’s going to be a little tricky.
pRactitioneR: OK, so you’re a little concerned about how you’ll han-
dle the social aspect of the change and how you’ll make time to
prepare your lunch in the morning, and this is still a change you’d
like to test out because you believe it will improve your health.
[reflection]
Once it is apparent that the client is ready to change, the discussion
can begin to shift toward action planning. Summaries can be useful when
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THE FOUR PROCESSES OF MI
transitioning clients to the “how-to” or “information giving” part of the counseling session. In a summary at the end of the building motivation process, revisit the main points of what the client has shared. Include:
• The original reason the appointment was made.
• Interesting information that was uncovered that seems pertinent.
• A few key reasons the client would like to change.
• Any major concerns the client has about change.
• The client’s general readiness to change.
This kind of summary helps the client organize his thoughts. It also
provides another opportunity for you to check in with her to make sure she is feeling heard and understood. A summary will also help transition to the planning process of the appointment. More information about summaries
can be found in Chapter 9.
After a brief summary, invite the client to consider how she might
make the change. You may ask, “How do you think you’ll go about mak-
ing this change?” This question provides the client an opportunity to think through the “how to” on her own first, and is known in the MI field as
“the key question.” It signifies transition from the evoking process to the planning process. Through asking this specific open-ended question you
invite the client to have the first stab at problem solving, giving the client autonomy. In the following dialogue, the practitioner provides a summary followed by an open-ended question to transition to the planning process.
pRactitioneR: I’d like to take a minute to recap what we’ve talked
about so far, if it’s OK with you.
client: Sure.
pRactitioneR: You made this appointment today because you’d like
to lose weight. We talked about different diets you’ve been on
and how those haven’t worked, and they’ve often left you feel-
ing worse about yourself in the end. You’re interested in making
some changes that are more personalized for your life. For start-
ers, you’d like to eat out less often. You believe it will save you
money and you won’t feel as full after meals. You’re worried that
it will take more time on the weekends to shop and plan for meals.
You’re also excited about the opportunity to eat more fruits and
vegetables and foods that make your body feel good. What did I
miss? [transitional summary]
client: Nothing. That sounds about right.
pRactitioneR: With this change of eating out less often, what ideas
do you have for how this could work for you? [open-ended ques-
tion]
Evoking 71
What Do I Do When My Patient Cries?
Evoking often results in an emotional response, especial y when the topic is body image or disordered eating. Therefore, before working with clients, create an environment where crying is viewed as a normal emotional response and ful y accepted. Keep those tissues handy! When a client tears up, it’s important to acknowledge that he or she is expressing emotion, and to find out where those feelings emerge from. One common response is, “I’m noticing some emotion as we discuss your frustrations with losing and gaining weight. Tell me about that.” When you acknowledge the emotion in a neutral manner, the client receives the message that it is acceptable to express what he or she is feeling, and is invited to consider how feelings influence her behavior.
Often when a client is emotional, there is more beneath the surface
to explore and uncover. On occasion, topics may arise that are beyond the capabilities of the nutrition or fitness practitioner, warranting a referral to a psychotherapist (see Appendix 1). When you take the time to real y understand all the elements of what the client is experiencing, both verbal and nonverbal cues, these internal conflicts can float to the surface; and if the clien
t is ready to explore these emotions, great healing can take place.
Pitfal s of Jumping the gun
A common mistake of nutrition and fitness practitioners is to jump to the planning process too quickly. Practitioners are often eager to start teaching the client new skills or brainstorming strategies for making the change easy.
Skipping the evoking process is especially tempting when there is little time for the session, or when the practitioner doesn’t expect to see the client for future appointments. However, the cost of jumping to the planning process too quickly is that the client leaves the practitioner’s office with a plan but with low motivation to follow through. The client is then less likely to make any changes, which can result in discouragement about behavior changes
altogether.
The amount of time spent in the evoking and planning processes
depends on clients’ readiness to change, and varies greatly between clients.
Some clients express excitement about a particular behavior change. With these types of clients, you may only need to spend a few minutes in the evoking process. Often, however, clients express overconfidence in their abilities to change. Therefore, it is still important to briefly explore with even the most seemingly motivated clients any hesitations, concerns, or potential barriers to change.
For other clients, a great deal of time may be spent eliciting change
talk. Clients less eager to change may need to spend several appointments in the evoking process. For a client who is referred to a dietitian and states,
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“I’m only here because my doctor made me come,” it may be helpful to
spend more time exploring the client’s concerns about his health.
The engaging, focusing, and evoking processes are important prep-
ping steps for the planning process. Let’s say you were going to paint a room in your house. What’s the first step? Preparing the walls. Holes in the wall may need to be filled, texturing may need to be done, and blue tape applied around windows, walls and ceilings. The preparation step of painting is the most important part. If you don’t take the time to prepare the walls, you will see bumps, cracks, and smudges after paint is applied. Just as in painting a room, when counseling with MI, significant preparation is needed before the client can begin to consider an action plan. Painting is the fun part. There’s something wonderful about picking a color and seeing it come to life on the wall. The most important part though is preparing your walls so the paint glides on smoothly. Take the time to engage with the client, build rapport, and build motivation for change. Only when the client has expressed an earnest desire to make a change can the planning process ensue.
Motivational Interviewing in Nutrition and Fitness Page 10
