strategies that may help you slow down a bit and now you’re ready
to give them a try. [summary] How would you feel about checking
in with one another in 2 weeks? [open-ended question]
client: That would be great.
pRactitioneR: Great, we’ll see you then.
The script above includes ten open-ended questions, five affirmations,
12 reflections, and four summaries. There were also a few closed-ended
questions, and at one point the practitioner provided the client with information. The primary instruments were the reflections and open-ended
questions, just like the violins of an orchestra. Like percussion instruments or certain wind instruments, the affirmations and summaries are used less frequently, but bring the music to life. The goal of the orchestra of OARS
is to elicit and highlight change talk, thereby moving the client forward in the change process.
PArt Iv
Beyond the Basics
chAPter 10
When Clients Aren’t So Sure about Change
The curious paradox is that when I accept myself just as I am
then I can change.
—caRl RogeRS
Not every client who walks through your door is going to be ready or willing to change. Appointments are made with nutrition and fitness profes-
sionals for a variety of reasons. Sometimes the client initiates the appointment and other times what brings the client in is a physician referral or a nagging spouse. Therefore, it is unrealistic to think everyone who books an appointment with you is ready to start implementing changes right away.
However, it doesn’t mean that the time you spend with the disinterested client is not valuable.
A skillful practitioner can use certain techniques to guide a client
toward change, or at least thinking about change. Just making that initial step, even if only contemplating it, can be a significant accomplishment for someone who was previously not even aware, or who was in denial of the
negative consequences of a behavior.
This chapter provides tips and strategies for evoking the internal motivation that is buried even in your least motivated clients.
reAdIng your clIent
In the first few seconds of the appointment, you will likely get a good sense of how the client feels about being there. Using both verbal and nonverbal communication, the client sends messages about her interest in change.
Crossed arms, furrowed eyebrows and a tilted head would all be strong
indicators that a client is angry or disinterested. As she begins to talk, she really starts to express how she feels about the appointment. Much of what 147
148
BEYOND THE BASICS
the client says about a behavior change can be categorized into three categories: change talk, sustain talk, and discord.
Change talk is anything the client says that favors making a behavior
change. Practitioners wish, dream and hope for change talk from their clients, especially the ones that seem disinterested during initial encounters.
Change talk sounds like:
“I really have to figure something out. I can’t keep going on and off
diets.”
“I hate how much money I spend when I eat out.”
“I’d like to start walking with my friend.”
“I really like yogurt. I didn’t think of that. I’d like to try that for breakfast.”
Sustain talk is anything the client says that favors not changing. Sus-
tain talk sounds like:
“I hate sweating.”
“I’m a bit of a picky eater, so this isn’t going to be easy.”
“It’s so much easier just to eat out for lunch.”
“I’m in too big of a hurry in the morning to eat anything.”
Expressing both change talk and sustain talk is a natural part of wad-
ing through the waters of ambivalence. Often you’ll hear change talk and sustain talk within the same sentence. How you respond to sustain talk and change talk will ultimately determine the client’s motivation and interest in making a change. In fact, the way you respond plays a significant role in whether the client remains physically and emotionally present in your office or heads for the door.
The collaborative nature of the counseling relationship is important
for creating an environment where the client can focus on motivation and change. A disruption in the relationship between client and practitioner can distract the client from this focus. This disruption is called discord between the two parties. Discord sounds like:
“I already met with a nutritionist and she just told me I had to cut out butter. I don’t even eat butter. This is probably going to be a waste
of my time just like the last time.”
“What do you eat? You probably eat all perfect, making the rest of us
look bad.”
“Send my son to the playground? Are you crazy?! We’ve got gangs!”
“You’re probably going to tell me I drink too much soda. Everyone’s
on me about my soda.”
When Clients Aren’t Sure about Change 149
Sometimes the client shows up
for the appointment angry or resent-
ful and expresses discord before the The collaborative nature of
practitioner has even had a chance to the counseling relationship
speak. Other times, discord develops is important for creating an
as a result of the practitioner mov-
environment where the client can
ing away from the spirit of MI and focus on motivation and change.
is likely to occur if the practitioner
starts pressuring the client to change.
For the most part, discord can be prevented or disarmed through
expressing empathy, supporting client autonomy, partnership, and collaboration.
MInIMIzIng sustAIn tAlk And dIscord
What’s the best way to minimize sustain talk and discord in a session and promote change talk? Communicate in a way that is consistent with the
spirit of MI and adjust your counseling style to avoid certain communi-
cation snags. When you hear discord, reflective listening works well to defuse hostility. Figure 10.1 includes examples of client discord along with responses that might make matters worse and alternative responses that
can turn the conversation in a new direction.
In their first MI book, Miller and Rollnick (1991) named common
traps that often increase sustain talk and discord. Those traps, and a few others, are described below along with solutions for steering clear of these pitfalls and staying the course toward client–practitioner harmony.
the Question–Answer trap
Nutritionist and fitness practitioners have been trained in conducting
detailed assessments, complete with a variety of questions about weight and disease history, a dietary or exercise recall, and a slew of other important topics. However, the downside of completing an oral assessment is
that the practitioner automatically is placed in the driver’s seat, pushing the client into a passive role. The practitioner asks a question, and the client responds to the question. The practitioner asks the next question, and the client responds. This continues on down the line until the assessment is complete. The practitioner is often writing down answers on a clipboard and clients are left wondering what the practitioner is writing and thinking about them.
If peppering clients with questions is not a productive process toward
change, then how does the nutritionist or fitness counselor collect this
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BEYOND THE BASICS
Client comment
Practitioner response that Practitioner response that
might promote discord
will likely reduce discord
“You’re not goi
ng to come
“Actual y, I am. Why are
“Everyone’s been pressuring
in here and bug me about
you resisting everyone’s
you to eat more and you’re
not eating enough, are
advice? Don’t you know
real y tired of it.”
you? The nurses have
they’re just trying to help
been nagging me to eat
you get better?”
more and I just don’t feel
like it.”
“Don’t tell me it’s because
“Yes, alcohol is one thing
“You think that your
I drink too much. I’ve
that raises a person’s
triglycerides might be
heard that one before and
triglycerides and you did
elevated for other reasons.
I’m not buying it.”
tell me last time that you
Would it be helpful to talk
typical y drink four beers a about those other reasons
night.”
today?”
“I already paid for this
“I’ll do my best, but I can’t “You are someone who
appointment, so you
make any promises.”
works hard for a living and
better make it worth my
takes great care to spend
while.”
your money wisely. You
seem worried that I’m not
going to be able to help
you.”
“My last trainer made me
“You never know!”
“You’re hoping to feel more
work out so hard I threw
supported in finding a level
up and developed shin
of fitness that doesn’t result
splints. You’re not going
in injury or discomfort. We
to have me pleading for
can definitely work together
mercy are you?”
on that and I hope you’ll tell
me if you’re feeling like I’m
pushing too hard.”
“I don’t know why I have
“Sorry, that’s our policy.”
“It sounds like you haven’t
to sit through your lecture
found our sessions very
every month just to get
useful. What could we talk
my food vouchers. You’re
about today that would be
wasting your time.”
more worthwhile?”
FIgure 10.1. Responding to discord.
important information without putting on the expert hat? Nutrition and
fitness practitioners attempting to adopt more MI skills have tried a number of techniques. One strategy is to have the client complete a preappointment questionnaire. The client answers a series of questions in writing before the first appointment. Others have revamped their oral assessments to include more open-ended questions and provide reflective listening statements
When Clients Aren’t Sure about Change 151
following each question, to make the assessment more conversational. This technique might keep the client from feeling like he is in the hot seat.
The ultimate goal is to avoid drilling the client with a long list of questions that can make the client feel judged, anxious, and uncomfortable, ultimately decreasing rapport and stifling the counseling relationship.
An Example of the Question–Answer Trap: Practitioner A
pRactitioneR A: Hello, Janice. My name is Stephanie. Please have a
seat. Your doctor has referred you to me because he is concerned
about your cholesterol. Let’s take a moment and discuss your eat-
ing habits. I’d like to look at what you ate yesterday. What did you
eat for breakfast?
client: Yesterday I had a cup of coffee and some cinnamon and
brown sugar instant oatmeal around 7.
pRactitioneR A: The single-serving packages?
client: Yes, I get the low-sugar ones and just add water.
pRactitioneR A: OK, how about lunch?
client: Yesterday we all went out to Mexican food for lunch. I had a
chimichanga, rice, and beans.
pRactitioneR A: Anything to drink with that?
client: Yes, a Coke.
pRactitioneR A: OK, how about in between lunch and dinner?
client: I had a granola bar around 4.
pRactitioneR A: OK, anything else?
client: No, just dinner. I had spaghetti with meat sauce and a salad.
pRactitioneR A: How much pasta did you have?
client: Maybe a cup of noodles and then ¾ cup of meat sauce.
pRactitioneR A: And what was in your salad?
client: I used romaine lettuce; sometimes I use spinach, but I was
all out. Then I put cucumber, tomato, some carrots, and Italian
dressing.
pRactitioneR A: OK, would you say yesterday was a typical day for
you?
client: Yes, except we don’t always go get Mexican food, but I do
usually go out for lunch when I’m at work. You see that’s the
problem. I eat out a lot I guess. It’s just too much in the morning to
get lunch together. I’ve tried it in the past, and I do it for a while, but then I start bringing my lunch and leaving it in the fridge at
work. If everyone’s going out, then I’m going to go too.
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BEYOND THE BASICS
In this dialogue, the client is defending herself and her eating habits.
Practitioner A has simply asked what the client ate yesterday, and the client has shifted into a defensive stance. It is possible to shift back to a more MI-style appointment, but it might be less damaging to the client–practitioner relationship to critically evaluate what information is absolutely necessary to help the client. You may not need as many details as you think in order to provide effective counseling.
In an MI appointment, the client is in the driver’s seat; therefore the client is going to decide what change she is interested in making regardless of her current patterns. However, there may be a place for some assessment-like questions at the beginning of the appointment, as they may help the client become more aware of areas he or she would like to change. The key is to keep it conversational by asking open-ended questions and reflecting the client’s responses. Doing so will minimize the question–answer trap.
Another alternative to a traditional food recall is to invite the client to share perceived dietary strengths and areas for improvement. For example, assessment questions could be tweaked to an open-ended, free-form style such as:
“Tell me about your eating habits.”
“What do you think are the positive aspects of your current eating
patterns?”
“What do you think are the negative aspects of your current eating
patterns?”
When it is necessary to conduct a more formal diet or exercise review,
another option is to ask the client to complete a food and exercise record prior to her visit, thereby eliminating the awkward nature of a detailed food and activity recall.
An Example of a More MI-Oriented Assessment: Practitioner B
pRactitioneR B: Hello, Janice. My name is Stephanie, I’m a nutri-
tionist here in the clinic. Please have a seat. Tell me about yourself
and what brings you in today. [open-ended question]
client: I’ve lived in this town all my life. I work full-time as a recep-tionist and have two kids in college.
pRactitioneR B: Well, great. I look forward to getting to know you
today. We have about 30 minutes to talk about anything related
to nutrition. So, what would
you like to start with? [open-ended
question]
client: Well, I’m here because Dr. Sawyer told me my cholesterol was
high. That was about 2 weeks ago. Since then I’ve been thinking
When Clients Aren’t Sure about Change 153
about what I can do. I read somewhere that oatmeal can lower
your cholesterol, so I’ve started eating oatmeal in the mornings.
It’s been about 3 days that I’ve been doing that.
pRactitioneR B: Your conversation with your doctor was a bit of a
wake-up call for you and motivated you to make a change on your
own. [reflection of change talk]
client: Yeah, it wasn’t that hard. My mom has high cholesterol, so I
know a thing or two already.
pRactitioneR B: And you’ve seen her make some changes. [continu-
ing the paragraph reflection]
client: She and my dad changed their diets a lot. I’ve seen what they’ve had to do. I think I eat pretty well at breakfast and dinner. It’s the
lunches that are a problem. Where I work, a core group of us go
out to lunch almost every day. We go to Mexican food most often,
maybe two to three times a week. Sometimes we go next door to this
Chinese place or Thai food. It’s a pretty important part of my day.
pRactitioneR B: You enjoy more than just the food when you go out
with them. [reflection]
client: I have fun with them. If I didn’t go, I’d be missing out. But you know, we don’t have to go to Mexican or Chinese all the time. A
few of them have been complaining that they’re gaining weight.
My friend Valerie has been bringing her lunch and staying at the
office for the last week. I bet she’d really be happy if we stayed in
more often. . . .
Practitioner B used reflections and open-ended questions to engage the
client, allowing her to talk about what she cares about most. The conversation between the client and practitioner builds a foundation where the client begins to feel comfortable.
Volleying questions and answers back and forth puts the client in a
passive role. Another way practitioners tend to take control is to “pounce”
on clients by starting a follow-up appointment with something like, “I have your goals from last week here in front of me. Let’s see, you said you would work on drinking eight glasses of water a day. How has that been going?”
Motivational Interviewing in Nutrition and Fitness Page 20