digging deep
A lot of issues surrounding food are not about food. Behaviors are products of one’s beliefs and values. Therefore, it’s important to dig a little deeper to determine what else may be going on that’s influencing behaviors and habits. The term digging deep, sometimes referred to as unpacking, is necessary when a client makes a
statement and you suspect there may A lot of issues surrounding food be more to the story. In other words, are not about food. Behaviors you may need to spend some time are products of one’s beliefs and
probing to uncover pertinent infor-
values.
mation about the client’s situation,
feelings, and reactions.
There are three main reasons to dig deep with the client.
1. Builds rapport. By taking the time to dig deeper, you express to the client that he matters. These probing questions show that you are
not only listening, but want to understand. In doing so, you build a
stronger connection with the client.
2. Enhances understanding. Through listening to the client’s answers to the probing questions, you can make sense of the issue at hand.
3. Enhances client awareness. In hearing himself talk about the issue, the client becomes more aware of his feelings and beliefs related to
food and behavior change.
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Statements that warrant digging a little deeper include:
“My husband has never had a weight problem, so he can eat whatever
he wants.”
“My mom does not understand how hard it is for me to lose weight.”
“I am not a vegetable person.”
“Certain foods make me sick.”
“I should really cook at home more.”
“I know I should just keep chocolate out of the house, or I’ll eat all of it at once.”
“I can’t control myself around carbohydrates.”
“I know I shouldn’t eat after 7 p.m.”
When you hear these one-liners and you get the feeling that there’s
more to the story, hold back from immediately probing with additional
questions. First, provide a reflection to the client’s statement to ensure that you understand the meaning of what was said. These reflections can be
followed by open-ended questions to further explore the client’s meaning.
Questions that can be used to dig deeper include:
“Tell me more about that.”
“What’s that like for you?”
“How so?”
“How does that make you feel?”
“Where do you think that idea came from?”
“What else?”
“What about that is important to you?”
“What is it about . . . that concerns you?”
Take the time needed to fully understand where the client is com-
ing from. Individuals often have complicated feelings about food, fitness, and body image. Slow down and encourage the client to explore underlying issues. In doing so, the client may experience an “ah-ha” moment or uncover reasons behind a particular behavioral pattern.
In the following dialogue, a practitioner uses reflective listening followed by a “Tell me more” to unpack the client’s personal meaning of the word binge:
client: I can’t even keep chocolate chip cookies in the house.
pRactitioneR: You feel out of control around them.
client: Yes, especially when they are fresh out of the oven. I’ll binge.
pRactitioneR: You eat more than you’d like to and feel guilty after-
ward.
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client: Yes.
pRactitioneR: You used the term binge. Tell me more about how you qualify a binge.
client: For cookies, I think four is too many.
pRactitioneR: OK, for you, eating four cookies results in feelings of
guilt afterward.
client: Yes, exactly.
“If Any” Questions
One way to express a nonjudgmental attitude is to avoid asking questions based on assumptions. Consider the question, “What concerns do you have about your high blood sugars?” Although this example is an open-ended
question, it assumes the client is actually concerned about having high blood sugar. To make it less leading and judgmental, try making it an “if any” open-ended question. For example, tweak the question to: “What
concerns, if any, do you have about your high blood sugars?” By qualifying a question with “if any” the practitioner gives the client a broad surface to work with, thereby enhancing autonomy. Asking a question based on an
assumption can be risky because if the assumption is wrong the client may feel trapped and become defensive or shut down. By simply adding “if any,”
you give the client freedom to answer in any way. Here are other examples of “if any” questions:
“What changes, if any, are you interested in making?”
“Which of these topics, if any, are you interested in discussing today?”
“What barriers, if any, might you run into?”
change in the Abstract (hypothetical Questions)
Another type of question is the hypothetical open-ended question: “If you made a change in this part of your life, how might it benefit you?” The hypothetical question gets the client to “try on” the idea and allows him or her to brainstorm through the potential barriers and the pros and cons.
Here are other hypothetical questions:
“If you were to attempt to cut back on soda in the next month, how
would you go about doing it?”
“If you were to talk to your spouse about needing his support for this
change, what would you say?”
“If you started packing a lunch next week, what foods would you need
to buy first?”
“If you started exercising this week, what activities might you try?”
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strengths-Based Questions
Self-efficacy, or the belief in one’s ability under certain circumstances, is one of the cornerstones in building motivation. If a client understands what must be done but has no confidence in his abilities to implement these necessary changes, not much else will help. People with low self-efficacy tend to believe tasks are more difficult than those with higher self-efficacy.
Guiding the client to talk about his strengths, skills, and accomplishments in related situations will help build self-efficacy moving the client one step closer toward making a behavior change.
The following questions are known as strengths-based questions
because they invite the client to reflect on previous successes in similar situations:
“What personal strengths have made you successful in making changes
in the past?”
“What’s helped so far in managing your nutrition?”
“What are you currently doing to manage stress in your life?”
“What are the main things you’re doing to support your overall health
and well-being?”
“Describe a time in the past when you were successful making a
change. What was that like?”
A strengths-based question is particularly effective if followed by a
statement affirming the characteristic outlined in the client’s answer, as in the following dialogue:
pRactitioneR: What have been your successes, if any, since our last
conversation? [open-ended question]
client: Oh, I can’t wait to tell you about last week. I thought about
what we talked about and ended up cooking four nights last week.
pRactitioneR: When you put your mind to something, you do it.
[affirmation]
client: Well it was important to me. If only to s
how that I could do it.
pRactitioneR: You wanted to prove to yourself that you were capable
of taking control of what you eat. [reflection]
client: Yes, there’s so much garbage out there; I’m just so tired of all the processed food and the way it makes me feel.
pRactitioneR: You noticed you feel better when you cook more at
home. [reflection] What was it that made the difference in you
reaching your goal last week? [open-ended question]
By using strengths-based questions, you can easily focus the client on
acknowledging the positive physical or mental changes being made or that
Open-Ended Questions 101
were made in the past. This technique is especially useful with clients who focus on why they can’t make changes. If a client comes across as victim-ized, or failing to take responsibility for her actions, encourage her to talk about what she has done in the past to support her health.
exploring goals and values
Everyone has specific goals, values, and priorities. By asking the client to share personal goals and values, you invite him to consider what he cares most about and examine how his values line up (or don’t line up) with his actions and life choices.
Eating behavior is commonly connected with deeply held beliefs and
values. Clients who abhor waste, for example, may find themselves consistently eating more than their bodies need in an attempt to avoid throwing away extra food. Examining this belief can help clients confront conflicting values. They are then free to decide how to change their behavior to accom-modate their beliefs, or decide whether their belief is something they want to hold on to or discard.
Often there is discrepancy between a client’s values and lifestyle
choices. For example, a client may say that he values good health and has a goal of preventing a second heart attack. He may also mention that he hasn’t been exercising at all in the last month. By asking a well-formed open-ended question to find out what’s important to your client, you can invite him to explore possible discrepancies between goals, values, and behavior.
When asking these types of questions, it’s important to do so without
judgment. The client will likely notice the discrepancy himself, if asked in the right way. Here are some examples of questions that elicit discussion regarding goals and values:
“What do you value in your life?”
“How does your desire to improve your fitness line up with your val-
ues?”
“How do you like to prioritize your time on the weekends?”
“What do you care most about in life?”
“How does this change fit in with your personal values?”
“How do your current food and fitness choices align with your val-
ues?”
reasons for change
By inviting the client to express personal reasons for change, change talk will likely occur. These questions are essential in an MI session. By inviting the client to voice reasons for change, and then reflecting back those reasons, you help the client become aware and conscious of personal
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motivations for change. Here are examples of questions that almost always evoke change talk:
“Why do you want to change?”
“Why is now a good time to work on this?”
“What are some possible advantages to . . . ?”
“How could making this change make your life better?”
“How are your current ways of doing things not working for you?”
looking Forward
Another way to elicit change talk is to invite the client to consider a future where the behavior change has been made, or to consider a future where
the behavior change has not been made. These questions encourage the
client to visualize possible long term benefits of change. Here are examples:
“If you decided to make this change, how would your life be different
in the future?”
“When you look ahead 5 years of being successful with this change,
how might your life be different?”
“Suppose you decide not to make this change. What might your life be
like 5 years from now?”
looking Back
Looking-back questions can also be effective in eliciting change talk. A looking-back question invites clients to consider a time when they were successful in making a change or life was generally better. In doing so, clients can compare these instances to the present to determine differences in attitudes and behaviors. Examples of looking-back questions include:
“Think back to a time when you didn’t struggle with your body image.
What was that like?”
“Was there ever a time when you didn’t feel this way about food? How
was life different back then?”
“Think back to a time in your life when you were more physically
active. What was that like?”
“How do your current thoughts and feelings about your health com-
pare to how you felt about it in the past?”
Often, in inviting the client to look back, she revisits a time before a problem arose. On occasion, doing so will result in the client revisiting a time when things were actually worse. If that’s the case, you can guide the
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client to explore how she has actually improved over time, which may lead to a strengths-based question or affirmation.
Querying extremes
Another way to elicit change talk is to invite clients to explore the best consequences of making the change and/or the worse consequences of not
making the change. Doing so invites the client to consider best and worst case scenarios. Here are some examples:
“What’s most important to you about making this change?”
“What’s the best thing that could happen if you made this change?”
“What concerns you most about your new diagnosis?”
“Suppose you continued on without making any changes. What’s the
worst case scenario?”
disarming Questions
Disarming questions invite the client to explore the reasons not to change.
Clients may not be expecting this type of question. For example, a practitioner might ask, “What do you like about [current unchanged behavior]?”
Disarming questions usually produce sustain talk. Therefore, it’s important to use these questions minimally. When done right, disarming questions
can alleviate resistance. At times, clients may even talk themselves into changing. Here are examples of disarming questions:
“What do you like about binging?”
“What do you like about eating at night in front of the TV?”
“What do you like about the weeks when you’re not active?”
“There are important reasons that you haven’t already made this
change. What are those?”
It is important to note that these types of questions require an incredibly nonjudgmental tone from the practitioner. Any hint of sarcasm or judgment may result in discord.
change rulers
Using a change ruler is a great way to assess client’s readiness, importance, interest, and confidence in change. A ruler question is one that asks the client to rate feelings about change on a scale, typically 0 to 10: “On a scale from 0 to 10 with 0 being not at all important and 10 being very important, how important is it to you to improve your energy by eating more regularly throughout the day?” Examples of change ruler questions include:
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“How ready are you . . . ?”
“How important is it to you to . . . ?”
“How committed are you . . . ?”
“How confident are you . . . ?”
; “How interested are you in . . . ?”
“How motivated are you . . . ?”
While the initial change ruler question is technically closed-ended, it’s the open-ended follow-up questions that are essential in eliciting change talk. After the client shares a number, find out more about why the client selected that number. Probing questions that typically follow change ruler questions include:
“Tell me more about your answer.”
“I noticed you didn’t pick a lower number. Tell me about that.” (This
question typically produces change talk.)
“I noticed you didn’t pick a higher number. Tell me about that.” (This
question typically produces sustain talk.)
“What could we talk about today that might increase your number?”
Some practitioners find it useful to keep a list of open-ended, evocative questions handy at each appointment that tend to be helpful during most sessions. Of course, the questions you choose to ask will ultimately depend on what you hear from your client. Figure 6.3 provides a sample list of evocative questions.
Putting It All together
The following dialogue includes many different types of open-ended questions to evoke change talk.
pRactitioneR: What are your plans for feeding your infant after she’s
born? [open-ended question]
client: I haven’t decided yet. I’ll probably bottle feed since it’s easiest.
pRactitioneR: At this point, bottle feeding seems like an easier
choice. [reflection] What is it about bottle feeding that seems like
the easiest choice? [disarming open-ended question]
client: Well, that way I can sort of pass the baby around to my mom
and other people in my family for feedings. Then the responsibil-
ity won’t always be on me.
pRactitioneR: You’re hoping others will help out, and bottle feeding
seems like the best way others might be able to help you. [reflec-
tion]
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• “What was it like to receive that diagnosis?”
• “What matters most about it?”
• “What are the best and worst parts?”
• “What is important to you about this change? What does it mean to you?”
• “How important is it on a scale of 0 to 10?”
• “How motivated are you on a scale from 0 to 10 to . . . ?”
Motivational Interviewing in Nutrition and Fitness Page 14