Motivational Interviewing in Nutrition and Fitness

by Dawn Clifford

  1. narrow the Focus

  There are many changes that could be made, but likely only one or two changes that the client would like to make. Determine the focus from the beginning of the session by agenda mapping to help the client choose. For example:

  “There are many changes we could talk about today that could help your

  daughter eat a wider variety of foods. Can I share a few directions we

  could take? [Wait for client response.] We could discuss fun ways to

  cut and serve fruits and vegetables, strategies for sneaking them into

  meals or snacks, or what to say at mealtimes that can eliminate the

  power struggle. Which of these ideas, if any, would be useful?”

  2. take every opportunity to Affirm

  It’s amazing what a little affirmation can do to increase the client’s self-efficacy, boost self-confidence, or defuse discord. For example:

  What to Do When There’s Little Time 169

  Engage

  • Introduce self and role.

  • “What brings you in today?”

  • “What were you hoping to get out of this appointment?”

  • Summarize and let the client know the al otted time for the appointment.

  Focus

  • “If it’s all right with you, I have a sheet of paper with different changes that clients often make. What jumps out at you, if anything, as a change you might be interested in making?”

  Evoke

  • “Why did you select that particular change?”

  • “How would that change make your life better?”

  • “How interested are you in making that change on a scale from 0 to 10, with 0

  being not at all interested and 10 being very interested? Why did you select that number?”

  • Reflect and summarize change talk.

  Plan•“How might you go about making that change?”

  • “Would you be interested in hearing other strategies that have worked for clients attempting to make that same change?”

  • Offer ideas.

  • “Which of these strategies, if any, interest you?”

  • “How do you see that fitting into your life?”

  • “How confident are you that you can make that change on a scale from 0 to 10, with 0 being not at all confident and 10 being very confident? Why did you select that number?”

  • “What might keep you from fol owing through with your plan? What ideas do you have for overcoming those barriers?”

  • Summarize change talk, highlighting the client-selected behavior change.

  FIgure 11.1. The four processes of MI when there is limited time.

  “It’s really amazing how you’ve been able to care for your daughter even with the postpartum depression and limited sleep you’ve been able to

  get because of the new baby.”

  3. Ask Permission before Providing Information

  By asking permission before providing information, you express autonomy and partnership, key components of the MI spirit. For example:

  “Would it be OK if I gave you some different recipes that were big hits with other children?”

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  4. check In

  It’s important to check in with the client frequently throughout a session to maintain engagement and demonstrate partnership. To avoid lecturing

  your client or long monologues filled with excessive information, break it up into shorter segments by sandwiching important information between

  two open-ended questions. (See elicit–provide–elicit in Chapter 5.)

  “What strategies have you already tried to encourage your daughter to

  eat a variety? [elicit] Would you be interested in hearing other ideas?

  [asking permission] Researchers have found that pressuring children to eat certain foods is rarely effective; what seems to be more helpful is serving the disliked foods repeatedly using different cooking techniques, sauces, and toppings. It’s also useful to make sure the child is hungry before the mealtime. Children are much more likely to try new

  foods when they are hungry, so spacing out meals and snacks is impor-

  tant. [provide] What do you think about all of that? [elicit]

  5. encourage client-centered goal setting

  The client is going to feel more empowered to change if she selects her own goals. By inviting her to set her own goals, you put the client in charge. She knows what works for her life. For example:

  “With all that we’ve talked about today, is there a specific tip or strategy you’d like to try when feeding your daughter? When would you like to

  try that? How often?”

  6. Address Possible Barriers

  Before your client leaves the office, offer the opportunity to troubleshoot.

  For example:

  “How confident are you on a scale from 0 to 10 that you can be success-

  ful at making the change you’ve decided on? What might get in your

  way?”

  These six strategies are demonstrated in the script below of a brief

  interaction between a personal trainer and his client at the YMCA.

  pRactitioneR: I know of a few exercises that you can do that won’t

  bother your knees. Would you be interested in hearing those?

  [strategy 3, ask permission]

  client: Sure. I know running is bad on your knees.

  What to Do When There’s Little Time 171

  pRactitioneR: Yes, running can be hard on your knees. Exercises

  that are easier on your joints include swimming, aqua jogging,

  water aerobics, and walking. Using the elliptical machine might

  also work, but you’d have to test it out. Which, if any, of these

  activities appeal to you? [strategy 1, narrow the focus]

  client: I’m not much of a swimmer, and I can’t really see myself join-

  ing my wife’s water aerobics class, but I could try aqua jogging

  while she’s in her class. How does that work, exactly? I mean, I

  could do that in the shallow end, but that might get boring after

  a while.

  pRactitioneR: That’s true. They make these floating devices that you

  wear like a belt and they keep you buoyant in the water so that

  you can continue the running motion in the deep end while stay-

  ing afloat. I’d be happy to show you at your next session. If you’re

  interested, you could bring your swimsuit and you can try out my

  aqua jogging belt to see if you like it. What do you think about

  that idea? [strategy 4, check in]

  client: Yes, I’d like to do that. [change talk—activation]

  pRactitioneR: Aqua jogging sounds like something you’d like to try.

  [reflecting change talk] If you do find that you enjoy aqua jogging,

  how many days a week do you think you’d be interested in fitting

  that into your schedule? [strategy 5, encourage client-centered

  goal setting]

  client: Well, I can definitely do it the two days a week my wife is

  doing her water aerobics class. [change talk—activation]

  pRactitioneR: You’re thinking that at the very least you’ll be able

  to do it 2 days a week since she’ll be doing her class at the same

  time. [reflecting change talk] What, if anything, might get in the

  way of you following through with your plan? [strategy 6, address

  possible barriers]

  client: The weather. Since it’s an outdoor pool, I’m sure I won’t feel

  like going in the winter. I’ve always admired my wife for sticking

  with her water aerobics class in the winter, but I’m not nearly as

  disciplined as she is.

  pRactitioneR: While you’re committed to staying active in the win-


  ter, [strategy 2, affirm] you’d like to find something that’s a little

  warmer on those cold, rainy days.

  client: Yeah, while my wife is out in the cold, I’ll be in here walking on the treadmill.

  pRactitioneR: You thought of your own alternative that easily aligns

  with your wife’s schedule and seems more enjoyable in the winter

  months. [strategy 2, affirm]

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  While this brief interaction between a personal trainer and client may

  not have all the pieces of a complete MI session, certain strategies were implemented to support client autonomy while still providing some guidance and direction. As a result, the client felt supported and empowered to attempt a new activity.

  coMMunIcAtIng wIth A tAlkAtIve clIent

  While encouraging clients to talk about a behavior change is an essential component of MI, an overly talkative client can make it challenging to promote change talk and set goals while still staying on schedule. Here are a few strategies that allow you to remain an active, caring, and compassionate listener while supporting behavior change.

  reflective listening and summaries

  By providing concise reflections and summaries, you demonstrate that you care about your client and wish to understand her motivators and barriers surrounding making a change. In addition, you can pull different pieces of what the client says together to help keep the conversation on topic and moving forward. In this example, the client is off in many directions and the practitioner reflects the change talk instead of the tangent.

  pRactitioneR: Describe a time when you’ve been successful in the

  past with making a change.

  client: I started training for a half marathon one time. I did the whole thing—joined a running group, started out slowly, bought new

  shoes; I really went for it. But then I got shin splints after about

  10 weeks of training and had to stop. I felt like such a failure. My

  brother was doing it with me and he was able to do the whole

  thing. I was totally jealous. But that pretty much sums up our rela-

  tionship. He’s been beating me out my whole life—he got better

  grades, did better in sports, dated cute girls, and the list goes on.

  For once, it felt like we weren’t competing, but doing something

  together and cheering one another on. And my body just couldn’t

  handle it. I had to sit on the sidelines and cheer him on, which was

  fun, but I really wanted to be out there with him.

  pRactitioneR: If it weren’t for the injury, you would have been right

  there with him. You were committed and excited about the change

  you were trying to make.

  By picking out the intention to change and presenting it, you encourage the client to speak more about it. If the practitioner had instead reflected

  What to Do When There’s Little Time 173

  the feelings of failure or inadequacy, the conversation would have taken a different direction.

  refocusing

  It’s easy for clients to start talking, and before you know it, you’re off in a new direction. A refocusing statement can help guide the client back on track or navigate in a new direction, depending on the client’s preference.

  In this example, the practitioner assists a client struggling with unintentional weight loss.

  pRactitioneR: From the handout we went over with tips for boosting

  calories, you chose adding supplemental nutrition shakes between

  meals as the change you’d like to make. How would your life be

  better if you made the commitment to drinking those on a regular

  basis?

  client: I’m sure I’d have more energy. And my son would stop telling

  me that I look sick. He’s been trying to make me different foods

  that are loaded with butter and sour cream. He’s a good cook. I

  appreciate his help. I try to think of ways I can do that, but I’m

  not as creative in the kitchen. I tried adding fats to the foods I

  cooked and it just turned out greasy and unappealing. The other

  day I drowned my salad in dressing because I knew I needed the

  extra calories, and it ruined my salad—made it wilted and soggy.

  pRactitioneR: Yes, we could talk about cooking ideas for boosting

  calories. Which topic would you prefer to talk about first—supple-

  mental drinks or ways to boost calories in your favorite recipes?

  client: We can stick with the drinks for now. That change seems

  easier to make.

  pRactitioneR: OK, you mentioned that adding supplemental drinks

  between your meals would give you more energy and get your son

  off your back.

  In this example, the client first voiced interest in adding between-meal nutrition shakes to boost calories and then expressed interest in a different change of adding more dietary fat to meals. While both changes are possible, it’s best to assist the client with one change at a time. The practitioner noticed the topic shifting and provided a refocusing response to invite the client to determine the best direction for the session.

  Breaking in with kindness and compassion

  When doing MI, it’s best to refrain from interrupting clients and fight the temptation to finish their sentences. However, when working with

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  extremely talkative clients, it may be necessary to break in now and then. A polite way to intercede is to ask permission and voice your timeline.

  client: . . . and then I told him that he has to go bowling with me

  because he has to get out of the house. The man never leaves the

  house except to get the mail. He sits around all day and watches

  TV and . . .

  pRactitioneR: If I may jump in for just a moment, I’m concerned

  we’re not going to be able to discuss the reason your doctor asked

  me to see you. Unfortunately, we only have about 10 minutes

  today and I want to make sure I have time to answer any questions

  you have about controlling your blood sugars. If it’s OK with you,

  I’d like to show you a list of changes clients often make to improve

  blood sugar control. Then perhaps you could select an area you’d

  like to talk more about. How does that sound?

  Giving the client an indication of the amount of time available may

  leave the client more mindful of the length of his or her responses. In the example, the practitioner makes it clear that he cares about his client and that it’s in the client’s best interest to keep the conversation on topic. This subtlety may not work with everyone, and for those extra-talkative clients, break in with what you see happening: “Janice, I’m having a hard time following you. If you wouldn’t mind, maybe we could slow down for a minute.

  You have a lot on your mind. What do you feel is the greatest challenge to controlling your blood sugars?” A statement like this one still allows the client to drive, just not in circles.

  Clients are going to do more talking as a result of MI, especially with strategically placed open-ended questions and reflections. However, both are essential in evoking change talk and ultimately awakening the client’s motivation. The key to short sessions is providing concise, mobilizing

  reflections and summaries that keep the conversations moving forward.

  Even in the shortest interactions, the practitioner can maintain the

  spirit of MI by implementing a few key skills such as guiding the client to come up with his own goals, asking

  The key to short sessions is

  permission before providing informa-

  providing concise, mobilizing

  tion, and affirming him when oppor-
/>   reflections and summaries that

  tunities arise. While these strategies

  keep the conversations moving

  may take a few extra minutes, they

  are worth every second when the

  forward.

  result is a more motivated client.

  chAPter 12

  Clarifying Health Misinformation

  and Exploring Unhealthy Beliefs

  The most confused we ever get is when we try to convince

  our heads of something our hearts know is a lie.

  —kaRen moning

  Health information is everywhere. Health is interesting not only to each of us, but also to the advertisers and marketing experts who want to capital-ize on any perceived health problems. Prescription and over-the-counter drug companies benefit by making people think there is something wrong

  with them that they can cure, alleviate, or treat. Commercial weight-loss programs want people to think they are overweight and out of shape, so

  the purveyors of those programs can serve up a unique solution . . . for a fee, that is.

  There is no shortage of health information, both credible and ridicu-

  lous, available to consumers. This chapter discusses MI techniques to use when guiding clients who know just enough health-related information to get themselves into trouble. In addition, this chapter focuses on unhealthy beliefs about food, exercise, and body image that emerge from incorrect or outdated information, and how common MI techniques can be used to

  help clients move toward making sustainable changes that enhance health.

  Standing in the checkout line in the grocery store provides a telling

  example of the onslaught of health information one receives each day.

  Celebrity weight-loss secrets glare up at us, cooking magazines display delightful pictures of healthy meals on the cover, and TV doctors seemingly stare straight at us, beside the comment “IS YOUR CHOLESTEROL

  TOO HIGH?” The truth is, we have access to a large amount of good and

  bad information when trying to manage our own health. It’s difficult, even as health professionals, to be completely immune to the subtle influences of this mix of credible and completely inaccurate information. Therefore, the 175