• A clinical dietitian has received three consults for brief nutrition education in addition to 15 initial assessments on the medical/surgi-cal floor.
• A personal trainer wonders how to fit MI into a session that also
includes teaching the client a series of exercises.
• A public health nutritionist has 15-minute sessions with each client before providing food vouchers.
• A physical therapist talks to her client about how his exercises are going at home while he warms up for 5 minutes on the stationary
bike.
This chapter homes in on the key essentials of MI and describes how
to maintain the spirit of MI even when interactions with clients are short.
While MI may take a little longer than lecturing a client, consider the cost of not using it. Without engaging the client and evoking change talk, the odds that the client will attempt a change are slim. Failure to assess readiness to change and ask permission before giving information may result in defensiveness and might reduce motivation. The cost of not spending those few extra seconds to maintain the spirit of MI results in a client tuning you out and putting you on the list of “I tried that once and it didn’t work.”
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Consider the following example of a nutrition practitioner who is in a
hurry and decides she doesn’t have time for MI:
pRactitioneR: Hi, Mrs. Wilson, I’m Natalie. I’m a dietitian. Your
doctor asked that I stop by to tell you about the right diet for
chronic kidney disease.
client: You mean I actually have a disease? The doctor told me my
kidneys weren’t looking too healthy, but he didn’t say anything
about a disease. Gosh. How long do I have to live?
pRactitioneR: Yes, technically your condition is called chronic kid-
ney disease, but don’t worry, some people have this condition for
years. I have a handout here with a few basic dos and don’ts for
patients with kidney disease. Why don’t you take a look? ( Gives
the patient the handout. ) As you can see, the most important
thing you can do is control your blood sugars and blood pressure
so that your kidneys don’t get worse. I saw on your chart that
your issue is blood pressure. So be sure to follow the diet for blood
pressure—you know, reduce salt, eat more fruits and vegetables,
that kind of thing. It’s important to increase your activity too. Do
you have any questions?
client: I don’t know. I’ve been keeping the salt shaker off the table, so that’s at least one thing.
pRactitioneR: Yes, that’s a good start, but there’s also a lot of sodium in food, so be sure to read your food labels too.
client: Right, I remember being taught that by my nutritionist. I
remember to do that sometimes in the grocery store. I couldn’t
believe how much sodium was in the frozen chicken nuggets I usu-
ally get for my grandkids to eat after school.
pRactitioneR: It adds up quickly. It’s important to always check.
client: I know, I know. I’ll try to be better about that.
pRactitioneR: Good. You can also control your blood pressure by
eating more fruits and vegetables and being more physically active.
client: Yes, I eat pretty well. I always have a banana in the morning
and some sort of salad at dinner.
pRactitioneR: Good, that’s a start. And are you exercising regularly?
client: Well, not really that often. I may get out and go shopping once in a while, but that’s about it.
pRactitioneR: Consider getting something more regular started, like
taking a short walk in the morning while it’s cooler.
client: I know I need to. I don’t like walking by myself. It’s boring
What to Do When There’s Little Time 163
and I’m always worried something bad is going to happen. Have
you watched the news lately? Just awful!
pRactitioneR: Yes, you’re right, safety is important. Well, maybe you
can find a friend to go with you. I have to go now, but I’d like to
schedule you an appointment to see a dietitian next time you see
your regular doctor. I’ll just leave this handout for you to look at
when you get home. Take care, Mrs. Wilson!
Now consider the dietitian who is short on time but chooses to use MI
anyway:
pRactitioneR: Hi, Mrs. Wilson, I’m Natalie. I’m a dietitian. Your
doctor asked that I come in to talk to you about your kidneys.
Would that be OK with you if we chatted for a few minutes? [ask-
ing permission]
client: Sure, that’s fine. I’ve met with a nutritionist before and I know what I’ve got to do.
pRactitioneR: What do you already know about good nutrition for
healthy kidneys? [eliciting what the client knows before providing
information]
client: Well, I don’t know about kidneys, I just remember being told
I couldn’t eat so much salt.
pRactitioneR: You’re right; limiting salt can help you control your
blood pressure, and controlling your blood pressure is a great way
to keep your kidneys healthy. Would you be interested in taking a
look at this handout I have on other strategies for keeping kidneys
healthy? [asking permission]
client: Yes, go ahead and put that on my chair with those other dis-
charge papers.
pRactitioneR: Sure, I can do that. Hearing about your kidneys yes-
terday must have felt a bit worrisome. [expressing empathy] It may
make you feel better to hear that by eating well and being active,
you can slow down how fast your kidneys lose their function.
[giving information]
client: Yes, that is good news, I guess. It’s nice to feel like there’s something you can do about it. [change talk—ability to change]
But at the same time, I’ve never done all that great on the diets I’ve
tried. [voicing ambivalence]
pRactitioneR: On the one hand you’re apprehensive about making
changes to your diet and on the other hand you’re interested in
maintaining your kidney function for as long as possible. [double-
sided reflection of the ambivalence]
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client: That’s right! I’d like to at least try.
pRactitioneR: I’m wondering today with this news regarding your
kidneys from your doctor, how interested are you in trying to
make a change in your eating habits or physical activity on a scale
from 0 to 10, where 10 is very interested and 0 is not at all inter-
ested? [assessing readiness to change]
client: OK. Oh, I guess at about a 6.
pRactitioneR: You’re on the fence about it right now, and yet you
didn’t choose a 4 or a 5. What made you pick a number just on
the other side of the fence? [open-ended question to evoke change
talk]
client: Well, I guess I’m just a little worried about my kidneys. I’d
really like to keep them healthy, so I’d like to think that this time
will be different. [change talk—reason to change]
pRactitioneR: This new diagnosis has you motivated to do things to
take care of your health. [reflecting change talk] If you’d like, I
can schedule you to see our outpatient dietitian in a month when
you return to see your doctor. How would you feel about that?
[as
king permission]
client: Yes, that’s a good idea.
pRactitioneR: Before I leave, I’m wondering if you can think of a
time you were successful in making a change that you were able
to sustain. [open-ended strengths-based question]
client: I did end up taking the salt shaker off the table after the last time I met with the nutritionist and it’s still off. I do salt my food a little when I’m cooking it, but before I was salting it in the kitchen
and at the table.
pRactitioneR: You were able to make a change you felt good about
and you’ve stuck with it. [affirmation] Making small gradual
changes over time can really make a difference. If you were to
make another small change to support your kidney health, what
would it be? [focusing question that emphasizes autonomy]
client: I’m thinking I can just throw the salt shaker out altogether at some point. I got used to the food with less salt last time and I can
get used to it again. [change talk—ability to change]
pRactitioneR: You noticed that while your food tasted different at
first, you adapted after you gave it some time. [reflecting change
talk]
client: Yes, it’s just a matter of throwing it in the garbage, so I won’t be tempted.
What to Do When There’s Little Time 165
pRactitioneR: It sounds like getting the salt out of the kitchen will
make it easier for you to make the change you intend to make.
Well, I have to go now, but it was nice meeting you, Mrs. Wil-
son.
While incorporating MI took a little more time, the client in the sec-
ond interaction has a much higher chance of making a change. The extra
minutes spent are sure to pay off. There were a few key MI techniques the practitioner used during that brief interaction.
The dietitian:
• Expressed interest in what the client had already learned previously.
• Used consistent reflections that highlighted change talk.
• Assessed readiness to change using a change ruler.
• Asked about previous successes and affirmed the client’s efforts.
• Asked permission before providing information.
• Demonstrated autonomy by inviting the client to consider one small
change to focus on at home.
• Expressed confidence that the client would be successful at making
a change when she was ready.
shortenIng the MI Process
The four processes of MI—engage, focus, evoke, and plan—provide struc-
ture to an MI session. (These four processes are covered in depth in Chapters 3–5.) It may take an MI practitioner several sessions before all four processes are covered, or only a few minutes. Timing depends on the client’s readiness to change and the practitioner’s availability.
If the client is expressing sustain talk or a general lack of interest in making a behavior change, then it may be several sessions before he or she is ready to discuss tips and strategies for change. In that case, a practitioner who is short on time could offer brief interactions that revolve around exploring ambivalence and evoking change talk. Alternatively, if a client is expressing significant change talk and seems ready to discuss change strategies, then shorter sessions that emphasize the planning process may be sufficient.
If client interactions at your While you may be pressed for
workplace must be brief, you may be
looking for the bare essentials of the time, it’s still important to display four processes. Below are strategies the same warmth, compassion,
for shortening each process, if time is and attentive listening.
limited.
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BEYOND THE BASICS
engage
It’s tempting to jump into planning when time is limited. While you may not have time to explore the client’s back story with the leisurely pace of an hour’s visit, it’s still important to display the same warmth, compassion, and attentive listening. Some busy practitioners find that it’s best to avoid questions like, “How are you feeling?” or “How are you?” because they
tend to result in answers that fail to assist much in building rapport and take the client in an unproductive direction. Instead use the time you do have to practice thoughtful, complex reflections that represent the true and intended meaning within your client’s statements. Engaging is not a process that begins and ends, but is clearly felt throughout your client interactions as you build a working relationship together.
Focus
When you have little time, the focusing process becomes essential. Invite your client to select just one behavior change area he’d like to explore further. Here is a short script from a physician who would like to address health behaviors but has little time to do so.
pRactitioneR: Unfortunately, we only have about 5 minutes today.
Which, if any, of these topics interest you as an area you may
want to work on? (Gives the client a handout with topics includ-
ing nutrition, fitness, smoking cessation, stress management, and
sleep.)
client: I know I need to work on my diet and get more exercise.
pRactitioneR: You’d like to make changes in your eating and activ-
ity levels. [reflection] Which would be more realistic for you to
address right now? [focusing]
client: Probably fitness. I probably need more help with that than
you can give me in 5 minutes.
pRactitioneR: Making a change in your activity level seems simpler.
[reflection]
client: Not easy, but at least easier than changing my food habits.
Clients like to have choices. However, if there is one particular behavior you’re required to inform the client about, give the client autonomy in deciding how he might go about
When you have little time,
making that change. For example,
the focusing process becomes
perhaps you are required by your
essential.
supervisor to talk to your client
about reducing the amount of soda he
What to Do When There’s Little Time 167
drinks. You can still give him several different strategies for cutting back on soda and invite him to select a strategy that might work for him. Of course, in the spirit of autonomy, make it clear to the client that not reducing his soda intake at all is always an option.
evoke
If time is limited, and you only have time for a few open-ended questions that evoke change talk, consider using a change ruler. By asking the client his readiness to change on a scale from 0 to 10, you’ll receive a concise response that gives you a good indication of his level of ambivalence. Follow up change ruler questions with probing questions that elicit change talk such as, “You’re at a 7, which tells me you have some hesitations, but you’re not at a 5 or 6, so what led you to choose a higher number?” Another essential question for evoking change talk is, “In what ways will making this change make your life better?” By encouraging the client to talk about what matters most in making this change, she will come to realize her internal motivators.
When time is limited, it may be tempting to ignore extensive sustain
talk from a client and move into the planning process before she is ready.
You may find that when you begin discussing possible strategies for change with the client, she is unable to come up with viable solutions and expresses disinterest in every option you provide. This is one sign that the client is not ready for change and it may be worthwhile to return to the evoking process and invite her to convey possible negative consequences of not making a change. In future sessions you could include topics such as her meaning of health and wellness, life goals an
d values, and social support.
Regardless of your client’s readiness to change, summarizing change
talk after asking some key evoking questions can help the client move forward. In addition, summaries provide a seamless transition if the client is ready to move into discussing how he might go about making a change. A
brief summary sounds like this:
“You’ve been living with HIV for a long time and recently started the
anti-retroviral therapy. You’re finding it challenging to keep up with
all the pills and suggested meal timing for the different medications.
You understand the importance of being consistent with your medica-
tions for keeping your immune system healthy and would like to make
a change in this area as long as you can stay within your food budget.”
Plan
A simple acronym developed by David B. Rosengren (2009) can help you
remember how to assist the client in the planning process when there is little time: FOCUS.
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• First ask permission. Asking permission only takes a second and is essential in creating a partnership between the practitioner and client where the client feels in charge and respected.
• Offer ideas. Within a brief MI session, ideas are offered with permission and ideally after eliciting ideas from the client.
• Concise. When offering ideas, keep explanations brief. Also refrain from offering too many ideas at once.
• Use a menu. If you only offer one or two ideas, you limit the chance that the client will find the idea acceptable. By offering a menu of
options for how to make a change, the client is more likely to find a
solution that works for him.
• Solicit what the client thinks. After providing information or a list of options for making the change, use an open-ended question to gauge
the client’s interest.
The four processes of MI do not have to be lengthy to serve their pur-
pose. In fact, if the client is expressing readiness to change, then these four processes may be covered in less than 10 minutes. An outline of a brief session that covers the four processes of MI is provided in Figure 11.1.
sIx strAtegIes to MI-InsPIred sessIons
MI concepts can be incorporated into a client interaction with minimal effort and significant pay off. If you don’t have time for a full session, here are six strategies for making your current interactions more consistent with MI.
Motivational Interviewing in Nutrition and Fitness Page 22