• “What would have to be different for the importance to be higher?”
• “How would your life be different after this change?”
• “How might this particular change get you what you want?”
• “How does this change relate to your personal values in life?”
• “What concerns do you have about what you are doing now? What bothers you most about it?”
• “What is good/working about what you do now?”
• “How might changing make your life worse?”
• “Who in your life would like this change?”
• “Who in your life would not like this change?”
• “How might others be able to support you in making this change?”
• “How is what you’re doing right now not working for you?”
• “How would your life be different if you did decide to make changes?”
• “How would changing make your life better?”
FIgure 6.3. Open-ended questions cheat sheet.
client: Yes. That way my boyfriend can get up in the middle of the
night to feed her and I can keep sleeping.
pRactitioneR: Bottle feeding in the middle of the night sounds easier
to you. I also heard you say that you haven’t completely decided
yet. [summary] What is it about breastfeeding that has you on the fence? [reasons for change open-ended question]
client: I know that it will be a hassle to actually prepare the bottle
in the middle of the night. Plus, I don’t want to buy formula all
the time.
pRactitioneR: Fumbling around in the dark with bottles and formula
isn’t your idea of a good time. [reflection]
pRactitioneR: At this point, how interested are you in breastfeeding
on a scale from 0 to 10, with 10 being very interested and 0 being
not at all interested? [change ruler]
client: I’d say that I’m at about a 6.
pRactitioneR: You’re on the fence about this. [reflection] Tell me why
you chose a 6. [probing question]
client: Well, I’m worried I’m going to want to go out with my friends
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or something and not feel like I can leave my baby if I breastfeed.
But my friends were telling me that breastfeeding would help me
lose the baby weight.
pRactitioneR: You’re feeling conflicted. On one hand, you want to
be able to continue to do the things you enjoy and on the other
hand the benefit of weight loss following your pregnancy is a big
motivator for you to breastfeed . [reflection]
client: Yeah, and I’m sure you’re gonna tell me about how it’s good
for my baby too.
pRactitioneR: You already know about some of the health benefits
for your baby. [reflection] What have you heard? [reasons for
change open-ended question]
client: I don’t really know the details, I’ve just heard it’s better for the baby.
pRactitioneR: Would you like to hear more about that? [closed-
ended ask permission question]
client: Not really. I don’t need to know the details.
pRactitioneR: All right. Let’s see if I got it all. You’re on the fence about breastfeeding, with your biggest concern being sharing the
load of the feeding and having the flexibility to go out with your
friends. You mentioned weight loss, your baby’s health, saving
money, and ease of feeding in the middle of the night as aspects
that are important to you. You’ve also said you’d really like help
from friends and family. Perhaps you’re wondering if you breast-
fed, how they might help take care of the baby so that you could
get more sleep. [summary]
client: Lord knows I’m going to need some help!
pRactitioneR: If you were to breastfeed, what are some ways your
friends and family could help you? [change in the abstract open-
ended question]
client: I’m going to need babysitters so I can nap. I’m sure there will be diapers that will need changing!
pRactitioneR: Right, so just being present during the day would be
helpful. [reflection] Would you be interested in hearing other ways your friends and family could help if you did decide to breastfeed?
[closed-ended, ask permission question]
client: Sure.
pRactitioneR: They can help by burping the baby after feedings,
doing laundry, and a breastfeeding mother needs more food,
so perhaps you can put your loved ones to work in the kitchen
Open-Ended Questions 107
cooking you meals and cleaning up afterward. [giving informa-
tion] What do you think about those ideas? [open-ended question]
client: I like the sound of that!
Open-ended questions are a pivotal skill in building motivation for
change. Well-placed open-ended questions guide the client to consider
motivations, values, barriers, skills, and reasoning not previously considered. Open-ended questions along with affirmations, reflective listening statements, and summaries make up the essential skills of a productive and effective nutrition or fitness counseling session.
chAPter 7
Af irmations
A person who feels appreciated will always do more than
what is expected.
—UnknoWn
So encourage each other and build each other up, just as
you are already doing.
—1
theSSalonianS 5:11 (NLT)
Clients often have the skills and education required to start making
changes. What they lack, however, is confidence in their ability to execute and sustain a specific behavior change. This belief in one’s ability to change is known as self-efficacy. Clients may come to you having tried many different ways to change their eating and exercise patterns. Unfortunately, it is common that they come to you only after feeling the harsh reality of many failures. If nothing else, what these clients need is a boost in confidence. This chapter discusses the use of affirmations, or positive statements regarding one’s character or values that ultimately result in strengthening self-efficacy, building rapport, and fueling change talk.
AFFIrMAtIons deFIned
MI uses many techniques to build and support self-efficacy, but none so much as the strategic use of affirmations. An affirmation is a positive statement regarding one’s character or values that acknowledges his or her strengths and efforts (Miller & Rollnick, 2013). The following statements are examples of positive affirmations:
“You are the type of person who works hard for what you have.”
“You really care about people.”
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Affirmations 109
“You want to spare people the pain you’ve been through.”
“You’ve really come to know what your body needs.”
“It’s important to you to be a good role model for your kids.”
“You’ve learned to trust yourself when you’re around sweets.”
“It can be hard to face certain problems. Coming here took courage.”
“You stuck to your goal even when it was challenging to do so.”
“You have a lot of compassion in your heart.”
“You know you can do it because you’ve done it before.”
Affirmations can be simple sentences like the ones above or they can
be found in the form of reframing reflections and summaries. When you
highlight the positive components of a client’s statement, you create an atmosphere of opportunity, unconditional positive regard, and support that permeates the entire
encounter.
The opposite of an affirmation would be a negative statement or bias
about the client. The idea that people will change if you make them feel bad about their bodies, eating habits, or physical activity patterns is problematic, and in fact the opposite appears to be true. When overweight and obese individuals feel discriminated against based on their weight they are more likely to gain weight (Sutin & Terracciano, 2013). On the other hand, people are more successful with change when they feel good about themselves.
The tendency to affirm is found
in the practitioner’s mindset. Con-
When you highlight the positive
stantly look for what clients do right, components of a client’s
what they’ve accomplished, and how statement, you create an
they are capable of realizing their atmosphere of opportunity,
goals. Changing your mindset to unconditional positive regard,
focus on, search for, and reflect the and support that permeates the positive might sound a bit tiresome. entire encounter.
However, with time and practice, it
becomes a way of life.
BeneFIts oF AFFIrMAtIons
Affirmations help clients recognize their strengths and capabilities. A well-placed affirmation can lead to change talk by drawing the client’s attention to the resources available within. In addition to supporting client self-efficacy, affirmations can help build a strong rapport between practitioner and client, boosting engagement. Affirmations benefit clients in a variety of ways. See Figure 7.1 for a list of 10 reasons to affirm your client.
In short, affirmations empower your client, encourage persistence and
reduce discord. These three key benefits of affirming clients are expanded upon with examples below.
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MASTERING THE MICROSKILLS: OARS
1. Empowers the client to believe in him- or herself in a specific area.
2. The client begins to internalize positive attributes.
3. Boosts overal self-confidence.
4. Encourages persistence.
5. Decreases defensiveness.
6. Opens people up to considering discrepancies and the possibility of change.
7. Strengthens or helps to repair the client–practitioner relationship.
8. The client feels supported.
9. Creates an atmosphere of positivity.
10. Supports forward momentum toward change.
FIgure 7.1. Top 10 reasons to affirm your client.
Affirmations empower the client
In order to develop a well-constructed affirmation, the practitioner must not only listen but also make some assumptions about the meaning within the client’s statements. There may be many opportunities throughout a
counseling session to reframe a client statement to highlight positive characteristics. When a client feels confident in his or her abilities and focuses less on the barriers, the client can begin to consider change. Here is an example of an affirmation aimed at empowering the client.
client: I know I don’t eat enough vegetables. When my sister was on
[a commercial weight loss program] she was eating vegetables all
the time.
pRactitioneR: You saw your sister succeeding and you think it would
work for you too. [reflection]
client: I guess so.
pRactitioneR: If you did decide to add more vegetables to your diet,
how would you go about it? [open-ended question]
client: I don’t know. I’ve never done much with them before.
pRactitioneR: You’re a little unsure about how to prepare them and
incorporate them into your meals and snacks. [reflection]
client: My sister has me over for dinner sometimes. One time she
made a stir fry that I really liked. I guess I could ask her how she
does it.
pRactitioneR: You’re not afraid to ask for help. And you’re even
willing to move out of your comfort zone and learn and try new
things. [affirmation]
client: Only when I have a good teacher. I bet it would be better if I
helped her make it one night.
Affirmations 111
Affirmations encourage Persistence
Affirmations are helpful in directing clients in a positive direction. Here is an example using an affirmation to encourage persistence. A client with HIV is seeing a nutritionist to aid in preventing symptoms of malnutrition.
client: Thinking about what and when to eat is a constant stress and
some days I’m just too tired. [sustain talk]
pRactitioneR: You’ve been through a lot, and some days it wears
you down; you’re here today because you’re not ready to give up.
[reflection and affirmation]
client: I can’t give up. I have to do this. [change talk]
pRactitioneR: Tell me more about why this is important to you.
This example shows how a few well-chosen words can drive the con-
versation toward change talk. Had the practitioner only used the reflection, it most likely would have gone more like this:
client: Thinking about what and when to eat is a constant stress and
some days I’m just too tired. [sustain talk]
pRactitioneR: You’ve been through a lot, and some days it wears you
down. [reflection]
client: I just don’t know what to do anymore. [sustain talk]
Reflections are powerful tools that encourage clients to expand on a
subject. People will tend to give you more of what you’ve reflected. In this case, the reflection only validated the client’s feelings of hopelessness, ultimately encouraging more sustain talk. By adding the affirmation to the
reflection, you are able to validate his feeling and reframe it into a positive and motivating statement.
Affirmations decrease defensiveness
While the ultimate goal of affirmations is to set the stage for change talk, they can also be used to help mollify defensiveness. For example, a client is referred by his doctor to a dietetics practitioner for nutrition education after being told his cholesterol is too high. The client is visibly agitated as the appointment begins, with his arms crossed against his abdomen and
looks at the practitioner with a cold expression.
client: I don’t even know what I’m supposed to be doing here.
pRactitioneR: You’re unsure about your purpose here today. [reflec-
tion]
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client: No, I know I have to get my cholesterol down. I don’t know
what you’re going to do about it.
pRactitioneR: You’re used to doing things on your own. [affirma-
tion]
client: Well if I don’t, no one else will.
pRactitioneR: You’re right, it is completely up to you. [reflection that supports autonomy] I can help if you’d like my help. [ask permission] What’s the best use of our time together today? [open-ended
question]
The affirmation, reflection, and open-ended question voiced by the
practitioner supported client autonomy. Instead of arguing for why she
could help him, the practitioner reframed the client’s statement, “I know I have to get my cholesterol down. I don’t know what you’re going to do about it,” into an affirmation. It’s not uncommon for people to enter counseling sessions with apprehension and defensiveness, especially if it wasn’t their idea to come in the first place. Engaging the client and understanding his perspective is an important part of dismantling his defensiveness.
crAFtIng AFFIrMAtIons
Affirmations are a type of complex reflection. Similar to a “continue the paragraph” reflection described in more detail in Chapter 8, the practitioner must interpret what the client has said and make a guess about
what kind of positive efforts the client has demonstrated. In order to avoid making the client feel judged, focus an affirmation around specific behaviors or characteristics instead of attitudes, decisions, or goals.
“Running that 5K showed you that you’re capable of far more than
you previously thought.”
“Talking to your mom about how she nitpicks about your food choices
took an incredible amount of courage.”
Play it safe when crafting affirmations. Pick a characteristic you are
certain the person possesses. If the client disagrees with you and begins to focus on why she does not agree with the statement, the whole focus of the appointment can be sidetracked.
Although affirmations are posi-
When crafting affirmations avoid
tive statements regarding one’s char-
starting with “I.” You are not the
acter or values, they are not the same
focus, the client is.
as giving praise or compliments.
There is a difference between giving
Affirmations 113
compliments and strategically using affirmations. A compliment has a tone of judgment or evaluation made by the practitioner. When crafting affirmations avoid starting with “I.” You are not the focus, the client is. Here are some examples of compliments and affirmations:
Compliment: “You look great!”
versus
Affirmation: “You worked hard this week and made it to all your workouts.”
Praise: “I’m so proud of you!”
versus
Affirmation: “You feel really good about what you’ve accomplished.”
Compliments and praise are not bad; they do give positive reinforce-
ment to specific behaviors. The downside emerges when clients get into
the habit of making changes for their practitioner’s approval instead of for their intrinsic value. You might be thinking, “But change is good no matter what, right?” The potential problem has to do with what happens when
the client stops doing well. Using the example above, if next week the client doesn’t feel like he looks great, he may be too ashamed or embarrassed to come back.
It is important to note that in order for an affirmation to be believable, it must be genuine. Some people are more likely to internalize insults and put-downs, so affirmations may be responded to with denial, ignorance, or total dismissal. This may be the case if an affirmation is given with a tone of superiority or mockery. As the practitioner, your tone of voice and facial expression will tell the client whether you are sincere. Notice the effect your affirmations have on the client. Some cultures do not respond well to them.
Motivational Interviewing in Nutrition and Fitness Page 15