“Now that we’ve talked about all of the different options for how to go about making this change, is there any one specific part that you’d
like to focus on?”
“Out of all of the things we’ve talked about, what specific change, if
any, would you like to try?”
“What ideas do you have of specific changes you’d like to work on?”
“We’ve just discussed a little experiment you’d like to try. Are there
any other experiments you would like to try after you leave here?”
“It sounds like you’re not quite ready to make any changes at this
point. I wonder if you would be interested in spending some time
on your own brainstorming all the ways this change might affect
your life and sharing what you come up with at our next appoint-
ment.”
Below are two sample dialogues. In the first dialogue, the practitioner is guiding the goal setting. In the second example, the practitioner is allowing the client to lead the goal-setting process.
Practitioner-Led Goal Setting
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Planning for Change 83
client: OK, sure, I can do that.
pRactitioneR: Great! Here are some recipes that I think you’ll like.
client: Yes,
that bean and corn salad recipe sounds pretty easy to
make.
pRactitioneR: OK, so four nights a week you will include some sort
of legume to your dinner meal. To be successful with this goal,
you will need to get to the grocery store. Be sure to write the
ingredients you need for your recipes on a list before you go.
client: Yes, I get lazy with shopping lists sometimes, so I will try to be better about that.
Client-Led Goal Setting
pRactitioneR: In your efforts to switch over to a vegetarian diet, you
mentioned a desire to add more protein-rich foods to your dinner
meals. We’ve discussed a few ideas. Which ideas appeal to you
the most?
client: I like the idea of adding beans to some of the meals I already
make. I’m also interested in trying out some of the premade items
you mentioned like vegetarian burgers and sausage. I don’t have a
lot of time to spend in the kitchen in the evenings and those ideas
are the easiest.
pRactitioneR: Given your time constraints and taste preferences,
adding beans and frozen items are a good place to start. As you
begin making this new change, is it helpful for you to have a goal
in mind, in terms of a certain number of days per week to add
these foods to your dinner meals?
client: Yes, I do better when I know exactly what I’m aiming for.
pRactitioneR: What sounds like a reasonable goal to start with?
client: I should probably start small, like two days a week.
pRactitioneR: OK, two days a week. What can I provide at this point
to help you reach your goal?
client: I can’t think of anything.
pRactitioneR: What ideas do you have for specific meals that include
the foods we’ve discussed?
client: I know I can make beans and rice, but I’m sure I can come up
with other ideas.
pRactitioneR: I have some vegetarian recipes here that include beans.
Would you be interested in looking at those for some ideas?
client. Yes.
84
THE FOUR PROCESSES OF MI
pRactitioneR: Here they are. Which, if any, of these sound appeal-
ing?
client: I like that corn and bean salad recipe. I’m going to try that
one this week.
pRactitioneR: You sound ready to make this change. What other
pieces of this protein-boost can I help you with?
client: Nothing. I think I can do this. I just need to make sure I’ve got the items I need on my grocery list. I get lazy with shopping lists
sometimes, so I will try to be better about that.
pRactitioneR: You sound excited to start adding protein-rich foods
to your dinner meals two days a week. Would it be helpful to talk
through the grocery shopping part before you go?
client: Yes, I guess I do need help with that part as well.
In the first dialogue, the practitioner pushes the client toward a spe-
cific goal without checking in with the client to see if it sounds feasible. In addition, the practitioner provides unsolicited advice and recipes without checking first to see whether the client needs the information. The cost of a practitioner-driven goal-setting process is that the practitioner may select a goal that is too challenging to meet, ultimately setting the client up to fail.
In the second dialogue, the practitioner kept checking in with the cli-
ent, asking her first whether naming a specific goal is useful and then inviting the client to set a feasible goal. Once the goal was set, the practitioner didn’t stop there, but continued to ask what additional information might be useful. Allowing the client to lead the goal-setting process supports client autonomy and gives the client confidence in setting personal health goals independently in the future.
If clients are truly in charge of selecting a specific goal or action, then they will likely come up with something they believe to be achievable and appropriate for their lives. However, there may be times when clients spec-ify goals that seem unrealistic. You may be tempted to try to talk your clients out of a particular goal. It is important that they feel supported in the goal setting, no matter what they choose. As opposed to arguing with clients about setting more realistic goals, the practitioner can ask questions to explore any potential barriers to change or offer a concern, as discussed previously.
setting up an experiment
When clients have trouble reaching unrealistic goals, they feel they have failed. The thought of embarking on a permanent lifestyle change can be overwhelming for some. You can make a behavior change less daunting for
Planning for Change 85
your client if you frame it as an experiment. By inviting a client to set up a temporary change, you give him the opportunity to try a certain behavior without making a lifelong commitment to it; it’s like dipping a toe in the baby pool instead of jumping into the deep end. Through the trial run the client can find out whether he is capable of the change, whether he likes the change, and also how the change influences others around him.
Testing out behavior changes can also be helpful in guiding the client
to visualize and reflect on it from many angles. As with any experiment, start by asking the client what factors she would like to pay attention to or notice as she attempts to make the change. This is like collecting data while performing a scientific experiment. If at the end of the experiment, the data collected by the client is positive, then the client may decide to make the change permanent. If the client finds that the change interfered significantly with other areas of life, then she may decide at her next appointment to select a different action item. If your client has trouble coming up with ideas of items to monitor as she’s making the change, here are some suggestions:
• Her overall satisfaction with the meal.
• How she feels after dinner.
• What her energy level is like.
• What her fullness level reflects.
• Regularity of bowel movements.
At a follow-up visit, speak to the client about the results of the experiment with curiosity, not judgment. By maintaining an aura of curiosity, the client can safely reflect on the experience with a fresh perspective.
In the following dialogue, the practitioner guides the client to attempt a behavior change for the first time in the form of an experiment:
pRactitioneR: You said you’d like to stop eating before you’re uncom-
fortably full. [reflection] How would you feel about testing out
this behavior change this week, like an experiment? [open-ended
question]
client: Sounds fun, I guess. What kind of experiment?
pRactitioneR: Perhaps you’d like to pick a few meals next week where
you sit at the table and make a conscious effort to eat slower. Then
you could report back at your next appointment with what the
experience was like. [information giving]
client: Yes, that sounds like a good idea.
pRactitioneR: Which days might be best to try this? [close-ended
question]
86
THE FOUR PROCESSES OF MI
client: Any day but Friday. We go out with friends on Fridays and I
know it will be much harder when I’m not at home. How about
Monday, Tuesday, and Wednesday?
pRactitioneR: You’d like to try out three different dinner meals on
Monday, Tuesday, and Wednesday. [reflection] What might be
useful to notice as you try this change? [open-ended question]
client: I’ll be curious to see how long it takes me to eat the meal. I
could also pay attention to how I f
eel afterward. If I overeat I have
a hard time sleeping. I have a feeling I’ll actually sleep better if I’m not feeling so bloated when I go to bed.
pRactitioneR: So you’d like to think about the time it takes to fin-
ish a meal when you slow down, how you feel afterward, and
how this change influences your sleep. [reflection] Anything else?
[open-ended question]
client: I think that’s pretty good. I think this change will really help.
The practitioner invited the client to set up an experiment and a spe-
cific goal. Once decided, the practitioner asked the client to monitor the outcomes of the experiment by asking, “What might be useful to notice as you try this change?” The client is leaving the practitioner’s office with a game plan. She is going to test the waters of change through conducting a small experiment and assess whether the benefits of making the change are worth her efforts.
AssessIng conFIdence And PerceIved BArrIers to chAnge
A primary goal of a nutrition or fitness counseling session is to help clients increase confidence in making a behavior change. Therefore, it’s a good idea to check in with them before they head home regarding their feelings about the action steps they plan to take. Through a short conversation
at the end of a session, the client and practitioner can explore any potential barriers to change and take a look at the client’s overall confidence in changing.
A simple scaling question, followed by probing questions and reflective listening, can help you assess a client’s confidence. Perhaps there is some last-minute troubleshooting you can do to assist the client in the change.
The following example includes a scaling question to assess confidence, followed by a series of questions to assess barriers and develop strategies to overcome those barriers.
pRactitioneR: You’ve mentioned an interest in trying to include an
afternoon snack each workday. How confident are you on a scale
Planning for Change 87
from 0 to 10 that you can make this change, with 0 being not at all
confident and 10 being very confident? [scaling question]
client: I’m at about 7.
pRactitioneR: Tell me about your answer. Why not an 8 or a 6?
[open-ended question]
client: Well, I’m hungry in the afternoon, so I’m sure I’ll remember
to eat. I’m just not sure I’ll remember to pack my afternoon snack,
so I may end up eating something out of the vending machine
instead. I’m not sure I’ll feel good about that.
pRactitioneR: So you’re fairly confident that you’ll be able to eat an
afternoon snack most days, but you’re not as confident that you’ll
be eating a healthy snack. [reflection]
client: Right.
pRactitioneR: What do you think will get in the way of packing and
bringing that snack with you to work? [open-ended question]
client: I think it’s just a memory issue. I’m afraid I’ll forget.
Motivational Interviewing in Nutrition and Fitness Page 12