Motivational Interviewing in Nutrition and Fitness
Page 5
priority to the client’s
to provide you with some resources for
needs.
obtaining free and reduced-priced meals in
our community.”
Evocation
The practitioner elicits the
“How would making this change make your
client’s personal motivation life better?”
for a particular change.
FIgure 2.1. The spirit of MI at a glance. Definitions based on Miller and Rollnick (2013).
The Spirit of MI 27
PArtnershIP
In the “good old days” of nutrition and exercise counseling, the counselor acted as the expert and the client acted as the student. The nutrition or exercise expert would rattle off the different types of dietary and exercise changes that the client needed to make and the client would sit and listen.
Over the years, researchers have found flaws with this style of commu-
nication. Clients would brace themselves for the abuse, admit their faults right at the start, and sit expectantly for their punishment. For the majority, this style of counseling irritated and humiliated clients, resulting in high no-show rates and few follow-up appointments. A practitioner might even say, “I did my best, he was just unmotivated.” William Miller, one of the founding fathers of MI, discovered that the counselor’s communication style largely influences the outcome of a session. Perhaps it isn’t that the client is unmotivated; the real issue is the counselor’s communication style.
Instead of writing off an unmotivated client, consider your role in evoking disinterest in behavior change.
In a consultation driven by MI, the practitioner avoids wearing the
“expert hat” and instead comes alongside the client in a partnership role.
Together, as a team, the practitioner and the client explore the client’s world.
The practitioner maintains an aura of curiosity as the client is guided to consider all angles of a behavior change. At times, tips may be provided, but they are offered if the client gets stuck and only with permission when the client is ready to change.
In an attempt to collaborate with the client, the practitioner might say,
“It sounds like you’re interested in packing a lunch more often to take to work, and that you’d like more ideas of foods you could pack. Would it be helpful to brainstorm together a list of packable lunch ideas?” By including the client in the process he is sure to leave your office with a list of foods he enjoys eating. Plus, he may feel more empowered to make the change
because he played an active role in coming up with a solution.
the expert trap
In working with the client instead of on the client, the MI practitioner avoids falling into the expert trap. The expert trap, a term coined by Miller and Rollnick, occurs when a practitioner gives the impression that he has all the solutions to his clients’ problems. Sometimes the practitioner can even come across as the “perfect eater” or “perfect exerciser” by describing solutions that have worked for him in the past. This can be problematic as it places the practitioner on a pedestal, making it hard to set a tone of partnership.
The expert trap occurs when imperatives are used. Imperatives are
statements that express a command such as “You need to . . . ” or “You
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MI BASICS
should. . . .” These phrases suggest that the practitioner is the expert on what might work for the client. While it is true that the practitioner may have more knowledge on the topic of nutrition and fitness, the client knows what will work with her current lifestyle patterns. Furthermore, bringing attention to the knowledge and expertise of the practitioner diminishes the feeling of a partnership.
To enhance the spirit of collaboration, replace imperatives with “Some
of my clients have found . . . What might work best for you?” For example, instead of, “You should check your blood sugars every morning,” you can demonstrate a desire for partnership by replacing the imperative with, “My clients who check their blood sugars every morning find that they are more successful at keeping them in their goal range. What have you found?”
Figure 2.2 shows statements that represent the expert trap as well as
alternative phrasing aimed to help create more of a partnership.
AccePtAnce
The practitioner brings an attitude of acceptance to the client–practitioner relationship. Acceptance, as described by the work of Carl Rogers,
is multifaceted (Rogers, 1995). The practitioner conveys this attribute by communicating absolute worth, affirmation, autonomy, and accurate
empathy.
Absolute worth
Also known as unconditional positive regard, absolute worth is built on a foundation of basic trust. The client is inherently trustworthy and thus respected as an individual. According to Miller and Rollnick, and based on the ideas of Carl Rogers, “When . . . people experience being accepted as they are, they are freed to change” (Miller & Rollnick, 2013). In essence, the practitioner creates an optimal environment for the client to grow, supporting the client with genuine care and respect. “R-E-S-P-E-C-T” is not only a catchy tune, but can also serve as an acronym to help you communicate in a respectful way (Adapted from www.budbilanich.com/r-e-s-p-e-c-t-dont-know-what-it-means-to-me):
Recognize the inherent worth of all human beings.
Eliminate bias and stereotypes.
Speak with people, not at them.
Practice empathy.
Empower people to change.
Create an environment of trust.
Treat clients as the experts of themselves.
The Spirit of MI 29
Practitioner response
Expert trap issue
Practitioner response
Partnership
expressing the expert
expressing partnership
strategy
trap
Client statement: “I know I don’t eat enough fruit. I could probably do a better job in that area.”
“One way I like to
Practitioner comes
“You’d like to eat more
Practitioner
get more fruits in my
across as the
fresh fruit. What ideas
invites client to
diet is by making fruit
“perfect eater”
to you have for adding
come up with
smoothies. I just add in
and does not first
more fruit? . . . Would
her own ideas
some fruit, yogurt, and
assess what types
you be interested in
and then asks
juice and blend it up.”
of changes interest
hearing one idea that’s permission before
the client.
perfect for a hot day like providing the
today?”
smoothie idea.
Client statement: “I’m looking for a new type of exercise that is more relaxing and easier on my joints. I’ve been under a lot of stress lately. Do you know of any?”
“You should try yoga. It
Practitioner uses
“Some activities
Information is
will make you stronger
the imperative, “You like yoga are geared
provided without
and help you manage
should . . . ”
toward stretching,
imperatives.
your stress better.”
strengthening, and
An open-ended
relaxation. What
question is used
are your feelings
to assess client’s
about those types of
interest.
activities?”
Client statement: “My blood sugars have been a little
higher than normal lately.”
“If you don’t get your
Practitioner
“You’d like to get your
Practitioner
blood sugars under
threatens the client. blood sugars down.
evokes concerns
control, your kidneys are
What concerns you
from the client,
going to fail and I know
most about high blood
and then asks
you don’t want to be on a
sugars? [client responds] permission to
kidney machine the rest
High blood sugars can
share negative
of your life.”
negatively impact a
consequences.
couple of organs in the
body. I’d be happy to
share more about that,
if you’re interested.”
Client statement: “I know I drink too much soda, but I hate the taste of diet drinks. I should try to drink more water, but it’s real y bland and boring. I need ideas for making water taste better.”
“I get bored with water
Practitioner comes
“Taste is important to
Practitioner
too. And just like you,
across as the
you when selecting
reflects what
I don’t like diet drinks.
“perfect eater.”
beverages. What ideas
is important to
What I do is add a little
do you have for flavoring the client and
bit of fruit juice to my
your water?”
then asks client
water.”
for ideas before
providing others.
FIgure 2.2. From expert trap to partnership.
( continued)
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MI BASICS
Client statement: “I like your idea of adding more vegetables to the meals I already make. That shouldn’t be too hard.”
“Yes, you could add
Practitioner gives
“What ideas do
Practitioner asks
vegetables to dishes
ideas without asking you have for adding
client for ideas
like tacos, pastas,
the client for ideas
vegetables to the meals first, then asks
sandwiches, pizzas, and
first and without
you already make?
permission before
soups. Just sneak them
asking permission.
[client responds] Would sharing additional
into your meals.”
you be interested in
ideas.
hearing some other
meals that often taste
great with added
vegetables?”
Client statement: “I think I could fit in walks on the weekends, possibly one on Saturday and one on Sunday.”
“You’re walking 2 days
Practitioner sets
“Walking 2 days a week Practitioner
a week, which is a great
client’s goal without is a great start.”
honors what feels
start, but you want to aim asking client first.
doable to the
for 5 days a week. Once
client.
you’re exercising more
often, you’ll real y start to
notice a difference.”
FIgure 2.2. ( continued)
Practitioners view their clients through their own set of lenses that
are shaped by their past experiences. Messages from friends, family members, and the media shape how we view others. Misshapen lenses result in disillusions or misconceptions like stereotyping, discrimination, and bias, all of which hinder the maturation of
respect for the client.
Misshapen lenses result in
Absolute worth is a key compo-
disillusions or misconceptions
nent of the spirit of MI as it empha-
like stereotyping, discrimination,
sizes the importance of respecting
and bias, all of which hinder
all individuals, regardless of race,
the maturation of respect for the
religion, socioeconomic status, sex-
client.
ual orientation, gender, or size. MI
practitioners can cultivate a deep
connection with clients when they clear their lenses and develop a genuine respect for all people. Clients respond positively when they feel cared for and accepted.
Accurate empathy
A practitioner demonstrates accurate empathy when she takes an active
interest in her client and attempts to understand her client’s perspective.
The Spirit of MI 31
Respecting Clients through
the Elimination of Weight Bias
One form of bias commonly seen in nutrition and exercise counseling is
weight bias (Swift, Hanlon, El-Redy, Puhl, & Glazebrook, 2012; Campbell
& Crawford, 2000). Health care professionals self-report bias and prejudice against overweight and obese patients. Obese patients report feeling stigmatized in health cares settings and are more likely to avoid routine preventative care (Amy, Aalborg, Lyons, & Keranen, 2006; Sikorski et al., 2011).
Those experiencing stigmatization are more likely to suffer from depression and report feeling less motivated to adopt healthy lifestyle changes (Eisenberg, Neumark-Sztainer, & Story, 2003; Puhl & Brownel , 2006; Vartanian
& Shaprow, 2008; Vartanian & Novak, 2011).
Nutrition and fitness professionals often believe people are responsible for their own weight and fail to lose weight because of poor self-discipline or a lack of wil power (Johnston, 2012). This belief system is unfounded and discounts the genetic component of body weight. It has been well researched that there are physiological mechanisms in place to counterbalance dieting efforts, making it nearly impossible for some people to lose weight and maintain weight loss (MacLean et al., 2011; Sumithran & Proietto, 2013). Some believe stigma and shame will motivate people to lose weight when, in fact, researchers have found the opposite to be true. Weight discrimination actual y increases risk for obesity (Sutin & Terracciano, 2014).
The practitioner doesn’t have to experience the same challenges in order to demonstrate empathy. She simply has to recognize and attempt to understand emotions that her client is experiencing.
Empathy is expressed in many ways in a counseling session through
the use of both verbal and nonverbal communication. The practitioner
shows empathy through a physical and calming presence, by inviting the
client to share more about his or her experience, and through attentive and active listening.
Here are examples of counselor statements that demonstrate empathy:
“You feel anxious about your new diagnosis because you don’t know
how it will affect your future health status.”
“When your mom gave you that look at the dinner table, how did it
make you feel?”
“When your husband made that joke about your weight in front of
your friends, it must have been really embarrassing.”
“I can only imagine how hard it must have been to hear your husband
say that.”
Empathy isn’t only communicated through words; facial expres-
sions, body language, and tone of voice are also essential in demonstrating
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MI BASICS
empathy. Any of the above statements could be phrased with a negative, condescending, mocking, or threatening tone, thereby failing to communicate genuine empathy. Therefore, demonstrating empathy involves the combination o
f a compassionate nonverbal communication style along with words
that communicate a general interest and desire to understand the client.
Autonomy
We as humans hate to be told what to do. In fact, we often want to do
exactly the opposite of what we are told we should do. What happens when clients are given complete freedom and respect to change or not change?
They are often more open to change! When they don’t feel pressured or
coerced, they can openly choose what’s best for them given what it is they value.
Comments that the practitioner may use to demonstrate client auton-
omy include:
“Yeah, you could do that. How would that work for you?”
“It’s ultimately up to you to decide how to respond to the doctor’s
concern. What do you think you will do?”
“That’s one way to look at it. Would you be interested in hearing what
other clients have tried?”
“You are the expert of your body and you get to decide what works
best for you.”
“Would you be interested in hearing some ideas that have worked for
other clients? Some have tried using alternative transportation to
work in order to gain more physical activity, others have tried using
lunch breaks for activity, and others prefer doing more active things
on the weekends. What do you think you will try?”
When imperatives such as “You should . . . ” or “You have to . . . ” are used, the client loses his or her sense of autonomy. While these terms sound harsh, practitioners often replace them with softer directive statements such as “What you’ll want to do is . . . ,” “What we’re going to do is . . . ,” or
“The best way to . . . is. . . . ” While these terms are less forceful, they can come across as very directive, crushing any hope for an autonomous client–
practitioner relationship and robbing the client of the freedom of choice.
Let’s say you are a client who is referred by a physician to see a nutritionist for “cholesterol lowering.” Which of the following professionals would you rather see?
Nutritionist 1
“You mentioned your father had a heart attack when he was in his 50s.
Given your family history of heart disease, it’s really important that
The Spirit of MI 33
you make some significant changes in your eating habits. The last
thing you want is to have a heart attack like your father. You’re really going to need to watch your diet and get more exercise.”
Nutritionist 2