Motivational Interviewing in Nutrition and Fitness
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The practitioner’s tendency to drive the appointment, however, can be what causes the client to express more sustain talk dismantling a carefully constructed client–practitioner relationship.
the expert trap
It is tempting to offer clients unsolicited advice. We all have the urge to tell others what has worked for us. We say things like, “I’ve been able to get
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more vegetables in my diet by making soups for dinner. Does that interest you?” or “I’ve found that parking a few blocks from my office and walking before and after work is an easy way to get exercise in. Would you like to try that?” The problem with the expert trap is that it gives the impression that you are the expert of your client’s problem. In actuality, the client is the expert of the client’s problem. If the advice giving involves stories from your own life, then you come across as the perfect eater or exerciser. Clients may feel that they cannot disclose certain pieces of information when talking to someone who might not be able to relate to their problems.
An Example of the Expert Trap: Practitioner A
pRactitioneR A: You know, I’ve struggled with the same problem
you’re having now. I just started packing my lunches the night
before and bringing them to work with me. I bet that would work
well for you since you’re so busy in the morning.
client: I guess so, but I don’t know what to pack. I just don’t like
sandwiches that much.
pRactitioneR A: Then you should do leftovers or something. It would
really help you eat better.
client: OK. Maybe I’ll try that.
pRactitioneR A: Great, I’ll add that to your goal sheet.
Just like with the question–answer trap, giving advice without asking
permission and offering choices pushes clients into a passive role. In MI sessions, clients are the experts and the practitioners are there to encourage them to explore their situations and come up with their own solutions.
Practitioners help guide clients toward change by finding, exploring, and supporting change talk as well as affirming the qualities that make them able to change. When the time is right, practitioners can also provide specific and targeted information, but this is always done after asking permission from the client.
When you start trying to problem-solve for the client, the client may
bear down with sustain talk or simply agree with you because she doesn’t want to let you down, but later fail to make the behavior change. As Miller and Rollnick (2013) put it, “motivation for change is not installed, but is evoked” (p. 23).
An Example of Avoiding the Expert Trap: Practitioner B
pRactitioneR B: You’re saying that mornings are busy for you, so
packing your lunch in the morning may not be the best time. [reflec-
tion] What might work better for you? [open-ended question]
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client: I could probably pack my lunch the night before. I don’t know
though, sandwiches might get soggy. I actually don’t even really
like sandwiches. What else could I pack?
pRactitioneR B: So you’re looking for something that won’t go bad or
get soggy during the day. [reflection] Some clients find that making
a little extra for dinner and then packing the leftovers for lunch
works. Others have found it’s useful to have this list of easy grab-
and-go lunch ideas handy. [giving information] I can give it to you
if you think it might be useful. [asking permission] It has foods like
yogurt, crackers and cheese, hummus and vegetables, or wraps.
What are your thoughts on those options? [open-ended question]
client: Leftovers could work because there is a microwave in our
break room. But I don’t always have anything left over to pack the
next day because my partner is a big eater. I’ll probably want to
take a look at that list you have also. I like most of the foods you
mentioned.
pRactitioneR B: It’s nice to have a back-up plan for when leftovers
aren’t an option. I also heard you saying that packing your lunch
the night before might work better for you than figuring out what
to bring in the morning when you’re in a hurry. [summary]
In this example, the practitioner simply reflected what the client was
saying and used open-ended questions to invite her to come up with a solution. When the client got stuck, the practitioner was there to provide suggestions of foods to pack, referring to ideas that have worked for other clients.
the scare tactics trap
There is a time and place for letting clients know the negative consequences of certain behaviors. However, harping on the dangers of certain negative health choices tends to backfire when clients have low perceptions of self-efficacy or response efficacy. Response efficacy is the belief that the solution provided is not effective in reducing the risk of harm (Witte & Allen, 2000). Scare tactics may not be the answer and they are not consistent with the spirit of MI. When scare tactics are used in health education, the audi-ence can become overwhelmed and immobilized with fear. They turn their
focus to coping with their fears with little energy left to focus on behavior change. Furthermore, scare tactics can come across as shaming and rarely result in lifelong behavior change.
An Example of Using Scare Tactics: Practitioner A
“I know you’ve had a rough first trimester, and you shared that you’ve
had some morning sickness. After reviewing your dietary recall, I’m
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concerned that your diet is lacking folate. You know if you don’t get
enough folate in your diet during pregnancy, your baby could have
neural tube defects. You really need to eat better.”
An Example of Avoiding Using Scare Tactics: Practitioner B
“You’ve had a rough first trimester. It sounds like you’ve really been
trying to eat a balanced diet and are having a hard time keeping food
down. I reviewed your dietary recall and noticed that your diet may
be low in folate. What do you know about folate and pregnancy? . . .
Would you like to hear more? . . . Folate is an important vitamin for
the baby’s developing nervous system. What do you make of this infor-
mation?”
Practitioner B starts with the client. She finds out what the client knows about folate and what concerns the client has. If the client isn’t aware of the connection between folate and the developing nervous system, the practitioner is there to provide this piece of information if the client is interested.
What cannot be conveyed through this passage is the practitioner’s tone of voice. Practitioner B was able to lay the facts on the table but did it in a way that did not frighten or shame the client. This was accomplished with the use of non-inflammatory language while making every effort to remain objective.
the cheerleading trap
You mean well when you cheer on your clients. There’s no denying you
want to see them succeed and that you are proud of them when they
make positive health changes. It’s one thing to provide encouragement
and affirmations, but it’s another thing to pull out your pom-poms. Figure 10.2 includes examples of cheerleading statements versus true affirmations.
While the cheerleading statements may sound motivating and encour-
aging, they can send the client the wrong message. They imply that the
client is only successful if he or she makes the change. Consequently, the client may be less likely to share when he or she is struggling. Another negative side effect of cheerleading is that the cli
ent may want to make a change only to please you as the practitioner. If that’s the case, the client is unlikely to maintain the behavior change long term. Finally, cheerleading can lead to sustain talk rather than change talk. By reflecting one side of a client’s ambivalence, it may lead him or her to argue for the other side, thus arguing against changing. Affirmations, on the other hand, are strategically placed to build self-efficacy and intrinsic motivation.
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Cheerleading
affirming
• “You’re doing so wel !”
• “You care about your health.”
• “I’m so proud of you!”
• “Fol owing through with your experiment is real y
something to feel proud of.”
• “Look at you go! I bet those
• ”You noticed that you feel better when you eat
cholesterol numbers are
more fruits and vegetables and that’s making you
dropping as we speak!”
feel like you can do this.”
• “You’re one of the best clients
• “You found that adding a vegetable to your dinner
I’ve ever had.”
wasn’t too challenging.”
• “Keep up the good work!”
• “You feel good about the changes you’ve been
able to make.”
• “You did it! You’re awesome!”
• “You were successful at coming up with some
ways to make this change easy.”
FIgure 10.2. Cheerleading versus affirming.
the Information overload trap
There’s just so much that you want to tell your clients. You begin thinking, “I may never see this client again; I have to make sure he has all the information he needs.” More is better, right? Not when it comes to MI and behavior change. Changing a behavior is hard work. If the client leaves with a long list of changes, it’s unlikely he will succeed. Behavior change is typically a product of motivation, not education. Sometimes education is needed for the behavior change to occur, but more often than not, the client already knows which foods are best but isn’t able to make the change for other reasons. Find out what the client already knows, and then find out what the client would like to know. Read the client’s verbal and nonverbal cues to determine whether he or she
is suffering from information over-
Behavior change is typically
load. If the client begins to look over-
a product of motivation, not
whelmed or develops a glazed stare, education.
then you may have gone too far.
In the section on information
exchange (Chapter 5) elicit–provide–elicit (E-P-E) is recommended to avoid information overload. By checking in with what the client knows and asking permission before you provide any information, you are better able to assess the client’s needs and then provide relevant and desired information.
By ending the information-giving portion with another elicit, you get a chance to assess the client reaction and then decide whether more information is going to be helpful or hurtful.
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An Example of Information Overload: Practitioner A
pRactitioneR A: You have celiac disease, which means you have dif-
ficulty digesting and absorbing gluten. Gluten is found in foods
containing wheat, barley, and rye. So you’re probably wondering
what gluten really is. It’s actually a compound that’s made from
two proteins: glutenin and gliadin. When mixed with water and
manipulated, these proteins produce an elastic compound that
ultimately helps breads rise. Now, when you eat it, your body
sees it as a foreign invader and attacks the villi in your small
intestine. They collapse and become far less efficient at absorb-
ing food. All of your symptoms are due to this immune response
to gluten.
client: So what does that mean? I can’t eat anything.
pRactitioneR A: So it’s bye-bye to bread, pasta, couscous, orzo, most
cereals, and flour tortillas.
client: Well my family is just not going to go for this.
An Example of Offering Information Using E-P-E:
Practitioner B
pRactitioneR B: Your allergy test came back positive for celiac dis-
ease. What have you heard of this diagnosis? [open-ended ques-
tion]
client: The doctor said I had to follow a gluten-free diet. I’m not sure about this. You hear so much about gluten-free diets recently. I’m
just not sure how to go about it.
pRactitioneR B: You’ve been thinking about this since you received
your lab results and you’re overwhelmed with the idea of switch-
ing to a gluten-free diet. [reflection]
client: Yeah, I don’t really know where to start.
pRactitioneR B: There are a few places we could start. Here’s a list
of topics for celiac disease including “what is gluten” “where is
gluten found in foods” “what happens if I eat gluten.” Which one,
if any, interests you most? [elicit]
client: OK. Let’s start with where gluten is found in foods.
pRactitioneR B: All right. Gluten is found in wheat, barley, and rye.
It can also be found in many oat products. So unless your oatmeal
specifies “gluten free” on it, you can assume it’s not. [provide]
What are you thinking about this information? [elicit]
client: I didn’t realize it was more than just bread. I’m not quite sure I know where those are all hiding in my foods.
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pRactitioneR B: Some of my clients find it helpful to go through this
sample menu together and pick out all the foods that have gluten
in them. Then I have an alternative gluten-free menu that shows
how you can change a few things in order to make it gluten free.
Would you like to try this activity? [asking permission]
client: Yes, that would really be helpful.
Which conversation would you rather have? Practitioner A talks at
the client, getting caught up in the science of the disease. Because Practitioner A was so focused on explaining the pathophysiology of celiac
disease he was not able to see that the client was getting overloaded with information. Since the information was given without permission or
engagement from the client, she responded with sustain talk. Practitioner B, on the other hand, uses an E-P-E technique to offer information and
in doing so is able to pick up on how overwhelmed the client was feeling at the beginning of the appointment. By checking in, expressing empathy, and supporting client autonomy by asking her to choose the topics, the
practitioner was able to provide the most helpful information. The time spent enhanced the client’s learning and she seemed prepared to start
voicing change talk.
the Jump-to-Planning trap
For many practitioners, talking about the “how to” of change is the most enjoyable part. Nutritionists are ready with their quick and easy meal
and snack ideas and are eager to pass them along to their clients. Fitness practitioners are eager to start showing their clients certain exercises and resources for community activities. Before diving into the “how to” it’s important to spend time engaging and building rapport, exploring ambivalence, and building motivation. Only when the client has expressed a strong desire to change is it time to discuss
how the client will proceed. Also, be Only when the client has
aware that some clients may seem expressed a strong desire to
ready to receive
your tips, tricks and change is it time to discuss how strategies, but then respond with sus-the client will proceed.
tain talk. A client might sit down and
immediately say, “OK, I know I need
to eat better. Tell me what to do. Give me a meal plan.” This may sound like a clear indication that you should get out a meal plan and start talking about what this person should and shouldn’t eat. However, this is a ruse.
Although the client is voicing change talk, he or she also wants to take a passive role. It would be helpful to reflect the meaning of this statement and see what the client really wants.
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the chat trap
Lastly, spending a good amount of time making “small talk” may be a
comfortable way to try to build rapport, but it is rarely helpful. Moreover, the flow of the appointment can feel jerky when you decide it’s time to get down to business. Building rapport happens through engaging the client in meaningful discussion about what brought him into the appointment. By
spending time reflecting and asking open-ended questions, the client gets to know your style and becomes more comfortable talking about important issues with you. Then, as certain themes become more prevalent, you are able to guide him into focusing on some specific areas where change could occur. “Chatting” seems to distract more than it helps.
MI works by finding, exploring, and supporting change talk. How-
ever, there will be many instances when clients are not moving toward
change, but instead are cementing their positions and arguing for the status quo. Although the client may seem to be the one with the problem, in reality the practitioner may benefit from taking a closer look at his personal communication style. You can’t control what the client will say, but you can certainly control what you say and how you say it.
chAPter 11
What to Do When There’s Lit le Time
Don’t count every hour in the day, make every hour in the
day count.
—UnknoWn
At first glance, MI may seem like a technique that requires an abundance of time—time that nutrition and fitness professionals don’t often have.
Consider these professionals who are usually short on time: