pRactitioneR: What might help you remember? [open-ended ques-
tion]
client: I could probably put a reminder on my phone that goes off 10
minutes before I leave the house.
pRactitioneR: And you think that this type of alarm reminder might
do the trick. [reflection]
client: Yeah, it’s the only way I remember anything.
Nutrition and fitness prac-
titioners often skip client-driven
Remember that motivation is
goal setting because they are
based on factors such as a client’s
short on time, or confident that
ability, confidence, and belief that
the counseling techniques used
efforts to change will work.
were sufficient to ensure client
success. However, if you take a
few extra minutes at the end of the appointment to check in with the client, he may feel a little more confident leaving your office.
The acronym GAB is a useful memory technique to remember the final
conversation before the client leaves the office. Before the client heads out the door, “GAB” with him for a few minutes:
Goals: Invite the client to share one last time what behavior or thought pattern he will attempt to change.
Assess confidence: Use a scaling question to assess the client’s
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THE FOUR PROCESSES OF MI
confidence in his ability to make the proposed behavior change or
thought pattern.
Barriers: Invite the client to consider any potential barriers that may get in his way and strategies to overcome them (if any).
It’s exciting when clients get to the point where they are ready to start making changes. You hear them start to talk about the future in a positive way, voicing mobilizing change talk such as commitment, activation, and steps they’ll take to achieve their goals. Remember that motivation is based on factors such as a client’s ability, confidence, and belief that efforts to change will work. Although the client may seem ready, there are reasons why he or she hasn’t already made the change. Check in with clients to
assess their confidence, troubleshoot their barriers, and provide relevant information when necessary. The action-planning process can be a rewarding time for both the client and the practitioner, as clients gain new strategies to test the waters of change.
PArt III
Mastering the Microskil s:
OARS
chAPter 6
Open-Ended Questions
The greatest compliment that was ever paid me was when one
asked me what I thought, and attended to my answer.
—henRy DaViD thoReaU
Questions are a customary component of conversation. The word interviewing in the term motivational interviewing suggests the important role questions play in evoking motivation from a client. By asking questions, the practitioner expresses interest in understanding the client. In the spirit of MI, the client is the expert of her life. Therefore, questions are used to elicit her expertise, thereby putting her in the driver’s seat of the change-making process. While a variety of different types of questions are used in a typical motivational interviewing session, the most important questions are those that evoke change talk. Asking questions is just one key skill commonly used in MI.
The four microskills of MI are:
1. Open-ended questions
2. Affirmations
3. Reflections
4. Summaries
Together, they are known as OARS. Much of what the practitioner says
during an MI session falls into one of these four categories. The primary purpose of using OARS is to elicit and emphasize the client’s change talk through reflective listening strategies, while attending for opportunities to affirm the client in his or her quest toward making a behavior change.
OARS will be covered in detail in this section of the book, with a
chapter on each concept. This chapter includes strategies for formulating open-ended questions that evoke change talk and encourage your clients to come up with solutions for changing nutrition and fitness behaviors.
91
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MASTERING THE MICROSKILLS: OARS
oPen-ended versus closed-ended QuestIons
Open-ended questions are worded in such a way as to elicit a meaningful and thoughtful response from the client. Conversely, closed-ended questions are those that elicit only a single word or a nondescriptive phrase.
Open-ended questions are preferred over closed-ended questions as they encourage the client to give voice to their thoughts, feelings, experiences, opinions, values, and motivations (see Figure 6.1). The following are examples of open-ended questions:
“What brings you here today?”
“What troubles you about this way of eating?”
“How have you dealt with that in the past?”
“How do you think this way of eating is affecting your health or well-
being?”
In contrast, a closed question, although necessary at times, tends to
limit the client’s response. Examples of closed-ended questions include:
“Do you like running?”
“How many times do you plan on doing this each week?”
“What is your height?”
“Which days of the week did you try this change?”
“Do you prefer weekdays or weekend days?”
“Do you like fruits and vegetables?”
Open-ended questions are more likely to evoke change talk than
closed-ended questions. Therefore, aim to ask open-ended questions at
least 70% of the time. While this concept makes sense conceptually, it can be challenging to carry out. The payoff is well worth mastering this technique. When the practitioner chooses just the right evocative open-ended question, the client can begin to process barriers and motivators to change.
Now and then a close-ended question may be the only option. For example, MI practitioners often ask closed-ended questions such as, “Is it all right if I show you some different topics we could discuss today?” or “Would
you like to schedule a follow-up session?” However, in general, open-ended questions are best for building a relationship with your client.
ForMIng An oPen-ended QuestIon
To turn a closed question into an open-ended question, it may help to use a sentence starter such as how, what, why, or tell me. Although a sentence starting with “Tell me” is not technically a question, it is a good way to encourage the client to elaborate on what was previously said, thereby
Open-Ended Questions 93
Open-ended questions are typical y started with the fol owing words or phrases:
“How . . . ?”
“What . . . ?”
“Why . . . ?”*
“Tell me. . . . ”
*Use caution when starting a sentence with why . It can easily be perceived as judgmental.
Closed-ended questions are typical y started with the fol owing words or phrases:
“Do you . . . ?”
“Have you . . . ?”
“Are you . . . ?”
“Will you . . . ?”
“Is it . . . ?”
“Can you . . . ?”
FIgure 6.1. Starting an open-ended question.
serving as an open-ended question. For example, if you say, “Tell me what that was like,” you will likely receive an in-depth response that gives you clues into the way your client processes experiences.
While “why” questions are open-ended, they come with caution tape.
The practitioner can easily come off as condescending or judgmental. The following “why” questions reduce autonomy and result in the client feeling pressured to change:
“Why don’t you want to do it?”
“Why can’t you?”
“Why h
aven’t you?”
“Why do you need to?”
“Why don’t you . . . ?”
It may be best to avoid these types of questions altogether. If “why”
questions are used, be mindful of your tone of voice to minimize sound-
ing judgmental. Figure 6.2 illustrates how closed-ended questions can be transformed into open-ended questions to encourage clients to elaborate.
BeneFIts oF oPen-ended QuestIons
There are many benefits to using open-ended questions. Here are just a few:
• Talk therapy. The simple act of talking can be therapeutic for some clients. Talking through struggles surrounding food and activity to a kind and listening ear can reduce stress and anxiety.
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MASTERING THE MICROSKILLS: OARS
Closed-ended question
open-ended question
• “Do you have any concerns about your
• “What concerns, if any, do you have
current level of physical activity?”
about your current level of physical
activity?”
• “Do you want to go to our diabetes
• “How would you feel about attending a
class?”
diabetes class?”
• “Can you tell me more about that?”
• “Tell me more about that.”
• “Do you like whole-grain bread?”
• “What’s your opinion of whole-grain
bread?”
• “How many days a week do you
• “Describe your gym patterns.”
currently go to the gym?”
• “What is your weight?”
• “Tell me about your weight or dieting
history.”
• “Do you want to be here?”
• “How do you feel about being here?”
• “Do you want to change the way you
• “What interest, if any, do you have in
eat?”
making a change in your eating habits?”
• “Can you think of any reasons for
• “What are your reasons for making this
making this change?”
change?”
• “Are there any barriers to making this
• “What barriers, if any, will there be to
change?”
making this change?”
FIgure 6.2. Turning closed-ended questions into open-ended questions.
• Ah-ha moments. The right open-ended question at the right time can result in an “ah-ha” moment for the client. Through certain evoking types of open-ended questions, the practitioner is inviting the client to think about personal thoughts, feelings, and values. Often, through
voicing out loud what the client is experiencing, he or she may find that a lightbulb clicks on and suddenly there is a sense of understanding or resolve.
• Enhances reflective listening. Reflective listening is a key skill in motivational interviewing that demonstrates empathy and builds trust. If clients are only responding to closed-ended questions with one word or a phrase, then the practitioner has little to reflect. However, when the practitioner asks open-ended questions and the client elaborates, there is more for the practitioner to reflect and highlight for the client to hear.
• Minimizes leading questions. Closed-ended questions lead the client into a certain response. For example, “How many servings of vegetables
do you eat in a day?” is a leading question because the client may feel uncomfortable admitting he does not eat any vegetables. Thus, it is implied that there is a right and a wrong answer. An open-ended question that may
Open-Ended Questions 95
better yield a truthful and more meaningful response would be “What are your eating habits like?”
• Demonstrates interest and respect. Open-ended questions tell the client that you value all that he has to say. Coupled with reflections, the client begins to feel that you understand him and have a genuine interest in his welfare.
• Elicits change talk. Perhaps the
most important benefit of open-ended Open-ended questions tell the questions is the potential for elicit-client that you value all that
ing change talk. Since the amount of he has to say. Coupled with
change talk in a session predicts client
success in making a change (Gaume, reflections, the client begins to Bertholet, Faouzi, Gmel, & Daeppen, feel that you understand him 2013; Barnett et al., 2014; Vader, and have a genuine interest in his Walters, Prabhu, Houck, & Field, welfare.
2010), it is important to ask questions
that result in change talk.
oPen-ended QuestIons: too Much oF A good thIng?
Questions are just one of the microskills of motivational interviewing.
Overusing questions can lead to the question–answer trap (see Chapter 10).
When a client is peppered with question after question, she may feel that the practitioner is either not listening or has taken the role of the expert within the appointment. To avoid rapid-fire questioning, aim to use reflections and open-ended questions in a 2:1 ratio—two reflections for every open-ended question. Notice how the practitioner alternates between reflections and open-ended questions in the dialogue below.
pRactitioneR: What concerns, if any, do you have about your blood
sugar being high? [open-ended question]
client: Well, I know it’s not good.
pRactitioneR: You’ve heard there are some health consequences to
high blood sugar. [reflection]
client: Yes, like I remember my mom had terrible trouble with pain
in her feet. Oh, it was awful.
pRactitioneR: You’ve seen first-hand what can happen and you don’t
want to go through what your mom did. [reflection] What other
things concern you? [open-ended question]
Notice that before the practitioner asks another question, he reflects
the client’s answer. Remembering to reflect after most client responses is a
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MASTERING THE MICROSKILLS: OARS
good way to ensure you will avoid the question–answer trap. Clients will feel heard and appreciated, which will likely result in additional sharing.
Practitioners often feel that knowledge is power; the more known
about the client, the better. While it is true that certain pieces of information about a client are essential, too much focus on assessment can hinder the client–counselor relationship. Drilling the client with assessment-based questions places the expert hat on the
practitioner and sends the client into
A collaborative partnership can
a passive role, often responding with
be easily dismantled in this type
short, simple answers. A collabora-
of Q-and-A dialogue.
tive partnership can be easily disman-
tled in this type of Q-and-A dialogue.
Firing assessment questions one after another could backfire, leaving the client feeling defensive and less likely to elaborate. A number of strategies can be used to allow for assessment data collection while still maintaining engagement with the client. Consider the following options:
• Engage before assessing. Take plenty of time to build rapport with the client prior to conducting an oral assessment. Miller and Rollnick
(2013) recommend refraining from asking assessment questions for the first 10 minutes of a session. Often, during the engagement process the counselor finds out a great deal about the client. The client may inadvertently answer many of the typical assessment questions during the dialogue that occurs naturally at the beginning of a session.
• Limit the number of assessment questions. Given all of the topics recommended within a complete nutritional assessment, as part of the NCP, an entire appointment could potentially be spent on
assessment alone. As a practitioner, it’s important to consider how much assessment is essential.
For example, consider a complete dietary recall. Dietitians and nutritionists are trained to obtain an accurate dietary recall by asking specific questions regarding types of food, cooking methods, and exact amounts. In
some cases, this information may be needed and in other cases, gaining this information will not change the focus of the counseling session. At times, certain assessment questions are mandated and may be unavoidable. When
this is the case, it may be useful to ask clients to answer those questions on a clipboard in the waiting room prior to being seen.
• Preappointment questionnaire. Some practitioners prefer to use a preappointment questionnaire. By asking the client to answer assessment questions prior to a counseling session, more of the appointment can be spent addressing the client’s specific needs. Some counselors ask the client to complete the questionnaire in the waiting room prior to the session and others send the questionnaire to the client via mail or email and ask the client to fill it out and send it in before the first session. If this method is used,
Open-Ended Questions 97
the counselor may have a better sense of the client’s primary concerns prior to the first visit and may be less likely to excessively question the client at the beginning of the appointment.
• Maintain OARS throughout assessment. Another strategy for maintaining engagement while collecting assessment data is to use open-ended questions, affirmations, reflections, and summaries. This often involves redesigning the counselor’s list of assessment questions to limit closed-ended questions. For example, instead of asking for recent weight changes, consider an open-ended question like, “Tell me about your weight history.”
In addition, counselors can demonstrate active listening through providing accurate reflections and summaries, turning an oral assessment into a casual conversation.
tyPes oF oPen-ended QuestIons
There are many different styles of open-ended questions and each has a
place within an MI session.
Motivational Interviewing in Nutrition and Fitness Page 13