Motivational Interviewing in Nutrition and Fitness

by Dawn Clifford

  chAPter 5

  Planning for Change

  After all, when you seek advice from someone it’s certainly

  not because you want them to give it. You just want them to

  be there while you talk to yourself.

  —TeRRy pRatchett

  The fourth and final process of MI centers on developing a plan for change.

  The practitioner allows the client to take the lead in coming up with a change plan. If the client gets stuck, the practitioner can provide suggestions to help the client along. Once clients enter into planning, keep in mind it is not an invitation to start pelting them with unsolicited advice or information. In this chapter we’ll consider ways to provide nutrition and fitness information without overstepping the client’s autonomy in the change process.

  InForMAtIon exchAnge

  Providing evidence-based information is an important part of nutrition and fitness counseling. In the spirit of MI, the practitioner acts as a guide and the client is the expert. The client is in charge of his body and behaviors and is given the respect to make his own decisions. However, you are there to help him brainstorm the best way to go about making the change or

  provide information about the latest research for a particular disease state, fitness plan, dietary supplement, or nutrient. During the action planning process, guide the client to consider multiple solutions for the behavior change. This may involve inviting him to come up with strategies, offering ideas that have worked for other people, asking him to devise goals, and troubleshooting the behavior change process.

  When done at the right time with the right tactics, information sharing 73

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  THE FOUR PROCESSES OF MI

  enriches the counseling experience for both the client and the practitioner.

  Below are some specific strategies for providing information in a way that keeps the client engaged as you navigate a behavior change plan together.

  Asking Permission

  Many nutrition and fitness practitioners fear they will not be able to tell their clients everything they need to hear in the time allotted. For some, this anxiety causes the practitioner to get to the point quickly and begin sharing information. We discourage the “get to the point” tactic, because it forces the client into a passive role. The benefits of motivational interviewing are apparent when clients take an active role, taking responsibility for making changes in their lives. To guide clients to take an active role, consider asking permission before giving any suggestions. Asking permission and respecting clients’ answers puts them in the driver’s seat.

  pRactitioneR: You care about getting your blood sugars into a nor-

  mal range and mentioned a desire to cut back on the amount of

  crackers you eat.

  client: Yes, I’ve been working at this for 15 years, but it seems like

  my diabetes has changed recently. So I can’t keep doing the same

  thing. I need to change the way I do things.

  pRactitioneR: How do you think you’ll go about making this change?

  client: You know, that’s where I’m stuck. I’ve been at this for so long, I’m not sure where to go from here.

  pRactitioneR: I have some suggestions you might consider. Would

  you be interested in hearing them?

  client: Yes, that’s what I’m here for.

  It’s important to note that if a client does not accept your request to give information, it is an indication that he isn’t ready to consider what you have to say. It doesn’t necessarily mean the client is unwilling to make any changes or take an active role in the behavior change process; it only means you may have misjudged the client’s stage of change or missed earlier cues of sustain talk. It’s also possible that you haven’t spent enough time engaging the client, or that the

  client feels forced to select a particu-

  The benefits of motivational

  lar behavior change that doesn’t align

  interviewing are apparent when

  with his interests.

  clients take an active role, taking

  It has been our experience that

  responsibility for making changes

  clients typically do not refuse sugges-

  in their lives.

  tions outright. It is more likely that

  the client will agree to listen to your

  Planning for Change 75

  suggestions, but if unready to make a change, he may explain why each

  idea you provide will not work. If a client turns down your offer to provide strategies that might help him along in the behavior change process, or expresses disinterest in a wide variety of tips and ideas, back up and revisit the engaging, focusing, or evoking processes.

  elicit–Provide–elicit

  Elicit–provide–elicit (E-P-E), also known as explore–offer–explore (E-O-E), is a step-by-step model that outlines how to sandwich information provided to the client between two open-ended questions (see Figure 5.1).

  Elicit

  The practitioner first elicits or gathers information on what the client already knows about the nutrition or fitness topic. By finding out what the client already knows, you can learn about the client’s stage of change and identify any signs of hesitation toward behavior change.

  Most important, when you do give information you can spend your

  time building on what your client already knows, instead of boring him

  with details he doesn’t need. In addition, the client may have misconceptions about the topic. Eliciting his or her current understanding can clue you in to opportunities to later correct misunderstandings, if needed. (For more information on clarifying misinformation, see Chapter 12.)

  By first eliciting what the client already knows about a topic, you can assess the client’s intellectual ability and communication style. In many Elicit

  • Ask the client what he already knows about the topic.

  • Ask the client what else he’d like to know about the topic.

  • Ask permission to provide information.

  Provide

  • Share only relevant information.

  • Use the client’s experiences as a starting point and assess what is already known.

  • Keep it short and sweet.

  • Avoid using imperatives, such as “You should” or “All you need to do is. . . .”

  Elicit

  • Check in with the client.

  • Invite the client to respond to the information provided by asking a question such as,

  “What are your thoughts on that?.”

  FIgure 5.1. Elicit–provide–elicit.

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  THE FOUR PROCESSES OF MI

  situations the client may feel uncomfortable if the educator uses language that is too advanced. If the client first verbalizes what he already knows about a topic or disease state, you can make sure to speak at the client’s level of understanding.

  In that same vein, you can also ask the client what else she would like to know about the nutrition or fitness topic before providing information.

  By assessing the client’s knowledge gaps, you are sure to provide information that aligns with her interests and needs. This initial elicit also typically includes a permission question before providing the client with the information. The act of eliciting the client’s current understanding and knowledge gaps while also asking permission before providing information honors the client’s autonomy and demonstrates a desire to meet the client’s needs.

  Provide

  As we suggested earlier, provide the information or strategies for change that build on what the client already knows or needs. During the provide stage, observe the client’s verbal and nonverbal cues to determine whether the client is engaged, interested, and understands the facts given. It’s important to offer information that is relevant, useful, and brief. When providing suggestions to clients, they will be more willing to consider what you’ve said if
given more than one solution.

  For example, if a practitioner were to offer practical strategies for

  increasing physical activity with a working mom, he might suggest taking the stairs at work, using alternative transportation, or walking during a lunch break. To strengthen client autonomy it can be helpful to follow up the list of options by saying, “It’s up to you.” By giving clients a menu of options and asking for their input, you will avoid situations where they leave the session feeling overwhelmed with food and exercise rules.

  Elicit

  After providing information, check in with the client to assess interest in and understanding of the ideas provided. The conversation reengages the client as you elicit further details about how the client feels or what she thinks of the information given. In this final elicit, open-ended questions are commonly used to check in with the client. Here are some examples:

  “What do you think about these ideas?”

  “How do you think this would work in your life?”

  “Which of these ideas, if any, interest you?”

  In the following example, the practitioner uses an E-P-E technique

  to provide the client with nutrition facts for end-stage renal failure with

  Planning for Change 77

  dialysis treatment. When the practitioner provides information, she gives a list of options from which the client can select. This dialogue begins in the middle of a session after the client has expressed change talk and appears ready to receive information.

  pRactitioneR: You mentioned earlier that it’s important for you to be

  able to be a part of your grandkids’ lives.

  client: I just want to be an active part of their lives, not just a grand-father who sits back and watches everything.

  pRactitioneR: You want to be in the game. What have you already

  heard about nutrition for dialysis? [elicit]

  client: Well, I remember my doctor saying I’m going to need to eat

  more protein, but I just hate those dialysis protein drinks.

  pRactitioneR: You’re right, increasing your protein will help to

  improve your overall health while on dialysis. There are many

  ways to increase your protein other than drinking supplements.

  Are you interested in hearing them? [asking permission]

  client: Sure.

  pRactitioneR: Some dialysis patients eat more eggs, whereas others

  prefer beef, poultry, pork, or fish. [provide] In fact, I have a hand-

  out on high-protein meal ideas for individuals on dialysis. Would

  this be helpful for you?

  client: Yes. That would be great. My wife will appreciate it.

  pRactitioneR: What are your thoughts on these ideas? [elicit]

  client: I think eating more meat is a much better way for me to get

  more protein.

  giving Advice

  The client benefits most if the practitioner is in a trusted but equal position, and gives the client a sense of unconditional acceptance. Advice giving is discouraged in an MI session because it makes the client feel that you have all the answers. While you may in fact have many solutions that you believe can help your client move forward, your goal within an MI session While you may in fact have many is to support your client to develop solutions that you believe can his own action plan. You are there help your client move forward,

  to clarify misinformation, offer sug-

  your goal within an MI session is

  gestions, and guide the client to make to support your client to develop meaningful and effective changes. his own action plan.

  Giving advice, especially without

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  THE FOUR PROCESSES OF MI

  asking permission first, will likely result in sustain talk, and possible discord within the counseling relationship, ultimately slowing the client’s process toward change.

  Even if the client asks you what he should do, he may not necessarily

  be ready to make changes. If he is in a contemplative or preparation stage of change it may be more helpful to respond by eliciting the client’s own thoughts and feelings.

  As in many aspects of MI, your choice of language during the plan-

  ning process is important. Avoid using imperatives such as “What you need to do is . . . ,” “You should just . . . ,” or “What you want to do is. . . . ”

  Whether the clients say it out loud or not, they will likely begin to argue with your point or share reasons why making that change isn’t possible.

  Clients need to talk themselves into change, not the other way around.

  offering a concern

  There may be times when a client starts voicing change talk for a behavior change that you don’t think is a good idea. Try to catch yourself before you say something like, “No, that’s not what you want to do.” Your role will be to help the client come to that conclusion on his own. Use reflective listening statements in a neutral tone of voice to gain understanding and evoke the client’s reasons and feelings. This also may be the right time to offer a concern. By offering your concern for the client to consider, you allow him to remain the expert and make his own decision about what he’ll ultimately do. For example, if a client is expressing interest in trying a very restrictive diet, it is appropriate for you to voice the reasons why it might not be a good idea. It is always the client’s choice what to do; however, it is the practitioner’s job to make sure the client has the right information to make a decision.

  When offering a concern, be honest and open with the client without

  arguing. The client may be less likely to argue or react with sustain talk if you ask permission before offering your concern.

  In the following example, the practitioner offers the client a concern

  she has about her interest in trying meal replacement shakes.

  client: I just need to drink those diet shakes for breakfast and lunch.

  Then, no matter what I have for dinner, I’ll still lose weight. I’ve

  already gone to the store and bought a batch of them. They’re

  really good.

  pRactitioneR: You’re excited to start making some positive changes

  in your eating patterns. [affirmation] What concerns do you have

  about how this might go? [open-ended question]

  Planning for Change 79

  client: None, really. I’ve tried diets like this before and I seem to lose a lot of weight in a short amount of time. So it does work.

  pRactitioneR: You’ve noticed in the short term that you lose weight

  when sticking to a diet with meal replacement shakes. What was it

  about this eating plan that made you stop? [open-ended question]

  client: I think I just wasn’t motivated enough last time. I’m newly

  single and so I really need to lose this weight since I need to get

  out there and start dating again.

  pRactitioneR: You’re anxious to start seeing some results. [reflec-

  tion] However, I have a concern about the approach you’ve cho-

  sen. Can I share my concern with you? [asking permission]

  client: Yes.

  pRactitioneR: I’m concerned that this dieting plan could be too

  restrictive. Researchers consistently show that weight-loss plans

  based on diet shakes help people lose weight in the short term but

  end with regaining the weight in the long run. Some of my clients

  have also experienced feelings of failure and body dissatisfaction

  following these types of plans. They often get tired of drinking the

  shakes over time. Of course, you’re the expert on your body, so

  it’s up to you what you choose to do. I just want to make sure you

  have all the information before you make your decision. What do

  you think about what I’ve just shared?

  In this exa
mple the practitioner gives the client a chance first to consider any risks involved with the proposed behavior change. When the client does not mention any concerns, the practitioner shares what she knows based on the latest research. She does so by first asking permission. She offers the concern and then elicits a response from the client.

  clIent-centered goAl settIng

  Within action planning, check in with the client and ask if there are specific goals he would like to make. In other words, what specific change is he interested in trying? Or perhaps there are certain thought patterns or beliefs he would like to explore on his own before the next appointment, like why he eats when he’s not hungry or why he feels compelled to finish his plate although he’s already full. There may even be a type of exploration activity or experiment that the client would like to attempt on his own.

  This is the client’s opportunity to define personal goals, making them more specific, or just to repeat intentions to change.

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  THE FOUR PROCESSES OF MI

  Here are examples of realistic nutrition- and fitness-related goals that a client may set during a session with a nutrition or fitness practitioner:

  • Sign up for a dance class.

  • Add a cooked vegetable to dinner three nights a week.

  • Eat more mindfully by turning off the TV off when eating dinner.

  • Start packing a lunch to take to work.

  • Provide a toddler with water instead of juice or soda between meals.

  • Look for healthy crock pot recipes and try one.

  • Fill out a food and feelings journal for 1 week like the one provided in Handout 5.1.

  The client may select a specific goal or a more general one. Some

  people work best with numbers and timelines, while others may be reluc-

  tant under that type of pressure. Therefore, it is important that the client leads the goal-setting agenda. Clients will feel more empowered to follow through with a goal they select themselves than they would with a goal you give them. Some open-ended questions you can use to assist the client in the goal setting process include: