Motivational Interviewing in Nutrition and Fitness
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“You mentioned your father had a heart attack when he was in his 50s.
How does that piece influence your health patterns today? . . . You
were referred here because of your elevated cholesterol. What was it
like to receive that information? . . . What do you think you will do
now? . . . How can I help? You’re the expert of your life and body and
you know what works best for you.”
In the first scenario, the nutritionist tells the client that he should value his health and tries to pressure him to be more motivated to change. This excerpt also includes imperative language. In the second scenario, the nutritionist poses several questions. These questions help draw out the client’s feelings related to a new diagnosis. In addition, through gentle questioning, the client is being asked to consider how he will respond to his new diagnosis. Client autonomy is enhanced when the client is asked what he plans to do instead of what he should do. Finally, the nutritionist asks the client how she can help. In doing so, she sends a message that the client is not alone in the predicament.
The client and nutritionist can collaborate to find viable solutions,
should the client be interested in changing. In this second scenario, the nutritionist displays the spirit of MI through offering to collaborate, asking the client to consider how the new diagnosis fits in with his values and concerns, and giving the client autonomy to choose how he will respond.
Affirmation
Clients often have the skills and education required to start making changes.
What they sometimes lack, however, is confidence in their ability to execute and sustain a specific behavior change. What clients need is a confidence boost. An MI practitioner best serves his clients when he acts as a hound dog, sniffing around for opportunities to affirm them.
Affirmations are statements regarding a client’s positive attributes.
Affirmations sprinkled throughout an MI session empower clients. At
times, opportunities to affirm are
obvious, and at other times they are An MI practitioner best serves subtle.
his clients when he acts as a
An experienced MI practitioner
perks his ears to listen for opportuni-
hound dog, sniffing around for
ties to affirm. In doing so, he creates opportunities to affirm them.
an environment where the client feels
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MI BASICS
respected, validated, and encouraged. In the following script, the practitioner affirms his client noticing both the obvious and more subtle client strengths.
client: It’s not that I can’t cook. My girlfriend actually raves when
I cook for her and her roommates. She even said that I should be
on cooking shows after I made this Italian stuffed shells dish the
other night. It’s just that I hate doing dishes.
pRactitioneR: You’ve got some serious talent in the kitchen. [affir-
mation] You’re also a good boyfriend and don’t want to mess up
your girlfriend’s kitchen. [affirmation]
client: Yeah, I guess I just need a magic cleaning wand.
pRactitioneR: Many of my clients are completely paralyzed in the
kitchen when it comes to blending foods and flavors. You’ve got a
leg up in this process since you have some skills. [affirmation] And
even though you don’t like cleaning, you don’t always let that get
in the way of treating your girlfriend to good food. [affirmation]
client: Yes, that’s true. I’m pretty lucky my mom taught me how to
cook.
In this script the practitioner uses three affirmations, and in doing so, highlights the client’s strengths in the behavior change process. Affirming the client demonstrates an overall appreciation and respect, further enhancing rapport with the client.
coMPAssIon
Be kind, for everyone you meet is fighting a harder battle.
—plato
Compassion is an essential attribute of a nutrition and fitness practitioner. Compassion, altruism, and empathy are tightly linked but are not the same. There is often confusion surrounding these terms, as compassion
often involves an empathic response and an altruistic behavior. Empathy refers to understanding and sharing feelings with another. Altruism is an action that benefits someone else but may not be a result of empathy or compassion. For example, a registered dietitian nutritionist may volunteer to give a speech to nutrition students, but the speaker may have an ulterior motive of promoting her private practice business.
Compassion involves genuine concern for the suffering of others, which
is beneficial for physical and mental health and well-being. Researchers studying the psychology of happiness and human flourishing have found
The Spirit of MI 35
that connecting with others in a meaningful way helps people to enjoy better mental and physical health, ultimately speeding up recovery from disease (Diener & Seligman, 2004).
The practitioner conveys compassion through giving priority to the
client’s needs and by actively promoting the client’s welfare. To remain a truly compassionate nutrition and fitness practitioner, consider the needs of your client. If the focus is on your self-gain, then it will be challenging to maintain an aura of compassion. For
example, if the counselor must report The practitioner conveys
a certain number of positive client compassion through giving
outcomes to a supervisor, or talk a priority to the client’s needs and client into a certain number of ses-by actively promoting the client’s
sions for profit, the appointment will welfare.
quickly become self-focused instead
of client focused.
Compassion is about seeking and valuing the well-being of others.
The counseling techniques described in this book are not meant to provide means to manipulate clients to change. At the heart of motivational interviewing is the general desire to do all we can for our clients’ well-being.
Maintaining compassion as a counselor can be a challenge at times.
However, compassion fatigue occurs when we try to fix our clients. Cli-
ents voice many reasons why behavior change is hard. If we view these as excuses, then we may start to lose compassion for our clients. However, if we attempt to put ourselves in our clients’ shoes and experience all of their life variables at play, we start to see that these aren’t excuses, but genuine and valid barriers, concerns, and feelings.
Compassion fatigue occurs when the practitioner tries to control
something he or she cannot control. A practitioner does have control over what he says and how he says it, but does not have control over the client’s response. Compassion fatigue can be avoided through good self-care and
focusing on the process of counseling and less so on the outcomes of counseling.
evocAtIon
Just as the term motivational interviewing implies, the counselor does do a great deal of interviewing to enhance motivation to change. The intent of the questioning is not to quiz or collect data from the client but to elicit or draw out certain feelings about a behavior change.
The practitioner is in some ways like a journalist. A journalist inter-
views experts in order to write a story. A good journalist is never the expert on the story. There’s no way for a journalist to be an authority on every topic written. The journalist becomes informed on a topic only through
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MI BASICS
researching it and interviewing individuals closest to the story. A journalist has to maintain an unbiased stance and an aura of curiosity. In addition, a journalist must use evocative questions to draw out the experiences, opinions, and emotions of his sources.
On the other hand, the intentions of the interviewing conducted by
an
MI practitioner are much different than those of a journalist. In journal-ism, the interviewing is for the journalist; in behavior change counseling, the interviewing is for the client. The interviewing is meant to prompt the client to talk about the behavior change. Motivation for change resides within the client. The practitioner elicits beliefs, feelings, ideas, and motivations from the client, often bringing the unconscious to the conscious mind.
In doing so, the client is able to discuss the behavior change in relation to what she cares about.
Sure, we can tell clients why we think they should change. But would
this motivate them to change? Not necessarily. In doing so, we may bring up reasons to change that they don’t necessarily care about. Therefore it’s most effective to elicit their personal reasons for change. Open-ended questions are best for encouraging clients to think about what’s important to them and how it relates to their eating habits. Here are some examples of open-ended questions that may be used to evoke reasons to change from
the client:
“What possible long-term consequences of diabetes concern you the
most?”
“What motivated you to make this appointment?”
“What concerns—if any—do you have about your eating habits?”
“What are the reasons you’d like to make a change?”
Eliciting thoughts and feelings about change not only helps you to
accurately highlight what is important to the client; it also helps the client to hear his true beliefs. Often, it’s not until something is said aloud that a person really reflects on the validity
of the statement. In that moment he
Eliciting thoughts and feelings
is able to consider whether the belief
about change not only helps you
represents a personal truth.
to accurately highlight what is
For example, clients often com-
important to the client; it also
plain about how big portion sizes are
helps the client to hear his true
when they are served food at a restau-
beliefs.
rant. In many cases, this is because
there is a common deeply held belief
that one must eat everything on his or her plate and avoid any food waste.
People then feel that large serving sizes are to blame for their overeating.
Through some well-spoken questions, your client may come to the real-
ization that she is needlessly overeating in order to fulfill a belief that no
The Spirit of MI 37
longer makes sense; she is eating in a way that harms her relationship with food. Used in this way, evoking is a powerful mechanism to help people
understand and work through the beliefs and thoughts that have developed over time.
In Figure 2.3, the parents of a teenage girl struggling with bulimia take the first steps in getting eating disorder treatment. Observe how the practitioner uses affirmations, accurate empathy, compassion, partnership, and evocation to lay the groundwork for a client–counselor relationship built on respectful communication.
The spirit of MI requires the practitioner to make the extra effort to be fully engaged in the counseling process. At times, it is more challenging to be empathetic, systematically affirming and supporting the client’s autonomy while going at his or her pace. Unfortunately, you can’t run ahead past the finish line and look back yelling, “I know how you can do it! I get it!
You just need to. . . . ” The counseling style is more predictive of the client’s motivation than the actual information you have to share.
Being committed to the spirit of MI will make you the type of practi-
tioner who clients feel can understand and relate to them. By seeing yourself as a partner in your client’s journey, you can focus on honing your skills of acceptance and compassion while evoking the very important and necessary details of your client’s experience. It is from the spirit of MI that trust is laid down as a foundation for the motivation for change to take root and grow.
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MI BASICS
Client: I’m so glad you’re helping my daughter with her eating issues.
It real y freaked us out when we overheard her throwing up her
food after her birthday celebration. We knew she was always self-
conscious of her body, but we had no idea she was bulimic.
PraCtitioner: Your daughter is real y fortunate to have parents who
Affirmation
care and who knew to seek help.
Client: Yes. The second we talked with her about it, we knew she
was going to need help. We got on the phone to her doctor the
next day.
PraCtitioner: You must have real y been concerned. It can be very
Accurate
hard when someone you love is hurting. I’m glad you are here. For
empathy
my younger clients, I like to meet with the parents separately at
Compassion
first since the support of family is so crucial in recovery.
Client: Yes, we real y want to help her and have no idea what to do.
PraCtitioner: You’re stumped and you’re hoping I have some answers
Partnership
for you. Perhaps we can put our heads together today and come up
with a game plan.
PraCtitioner: You mentioned that Stephanie has always been self-
Evocation
conscious of her body. When did you start noticing her negative
body image?
Client: Gosh, as early as second grade. I have a daughter in high
school and she likes to read popular magazines. She’d leave them
lying around the house and Melanie would pick them up and start
asking me about different articles in there. Some of the articles had
some shocking adult content, so I had to tell my older daughter
to keep those in her room. But ever since then I could tell that
Melanie started to see herself differently. She real y looks up to my
older daughter and I could tell she started comparing herself. I told
her she had a great 8-year-old body and not to worry about it, but
needless to say, that didn’t do much.
PraCtitioner: Despite your best efforts to protect your daughter, she
Affirmation
continues to be dissatisfied with her body.
Client: Yes. It’s like nothing I said mattered after that.
PraCtitioner: It’s like your voice was lost in a sea of voices from the Compassion
media. Sometimes we hope that a megaphone will do the trick.
Client: Yeah, that’s right.
PraCtitioner: What else can you tell me about the messages your
Evocation
daughter ran into throughout her childhood about weight, food,
and exercise?
FIgure 2.3. The spirit of MI alive in a counseling session. Notice the various components of the spirit of MI throughout this script excerpt.
PArt II
The Four Processes
of Motivational Interviewing
chAPter 3
Engaging and Focusing
Attention is the rarest and purest form of generosity.
—Simone Weil
MI is a bit of a dance. The dance of the MI counselor with the client flows gracefully and even seems to have rhythm to its steps. While the dance is not choreographed, there is structure and framing. As with ballroom dancing, there is a leader and follower. The counselor acts as the lead dancer, and provides gentle guidance across four distinct areas of the dance floor, known as the four processes of motivational interviewing:
1. Engaging
2. Focusing
3. Evoking
4. Planning
This chapt
er begins with an overview of the four processes and follows
with details of the first two, engaging and focusing. The third and fourth processes, evoking and planning, are covered in Chapters 4 and 5.
An overvIew oF the Four Processes oF MI
The first process of MI is the act of engaging the client. The client is invited into a conversation that is warm and involves understanding how the client is feeling as a primary starting point. The counselor attempts to build rapport through posing inviting, nonthreatening, open-ended questions
and uses reflective listening skills to demonstrate interest in understanding the client’s story. Through the engaging process the counselor attempts to understand what the client is hoping to gain from the appointment. While 41
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THE FOUR PROCESSES OF MI
the engaging process starts the session, the counselor aims to maintain that connection with the client throughout. Engaging the client isn’t just about introducing oneself and finding out why the client made the appointment.
It’s about demonstrating from that very first moment that the client matters. This is demonstrated through being an attentive listener.
The second process involves helping the client to select a focus for the session. The client is asked what changes, if any, he or she is interested in making. Some clients arrive with a particular dietary or exercise change in mind that they’d like to try. Other clients have no idea what changes to make for a new diagnosis such as heart disease or diabetes. And others have little interest in making any changes. Considering all of the possibilities, it’s important to allow clients to lead the focusing process. If a particular behavior change is not expressed by the client, the practitioner can provide various topics in the realm of nutrition and fitness and the client can select which topic is most appealing.
The third process, evoking, is centered on building motivation for
change. The counselor asks open-ended questions that invite the client to explore reasons to change and how this change relates back to personal values. Evocation is part of the spirit of MI, and key in building motivation to change. Evoking questions are placed throughout a session with a primary purpose of promoting change talk, or phrases and sentences from clients that indicate interest in making a change.
Once the client seems ready for change, the conversation shifts to the