symptoms (in this case, constipation) while still honoring one’s palate. It’s important that clients discover foods that both support a healthy body and a pleasurable eating experience. Clients often need significant guidance in discovering and redefining a healthy relationship with food.
coPIng wIth crAvIngs
In an effort to lose weight or manage a disease, many attempt to elimi-
nate certain high-fat, high-sugar, high-calorie foods. Restricting favorite foods might seem easy at first, but then the challenges of life get in the way—a holiday party, a birthday celebration, a tantalizing advertisement for a missed food, or a sad, lonely evening at home with the ice cream container calling from the fridge. For the majority of people, restriction leads to overeating, preoccupation with food, and body dissatisfaction (Polivy et al., 2005; Spoor et al., 2006). Researchers have found that individuals who simply plan on dieting will eat more in anticipation of the restriction (Urbszat, Herman, & Polivy, 2002). That’s right—just thinking about restricting is enough to enhance the urge to eat. In short, restriction is a recipe for overeating.
habituation
If you were told today that starting tomorrow you would never be able to eat ice cream again, what would you eat tonight? You’d eat ice cream, of course. And chances are good that you’d head to the store to buy a nice big gallon of ice cream even if it was freezing cold outside and the last thing on earth you actually felt like eating. How do you help your clients break this vicious dieting cycle? The answer seems almost counterintuitive, but a growing body of research supports the concept of habituation, or repeated exposure to a stimulus that leads to a decreased response (Epstein, Temple, Roemmich, & Bouton, 2009). In other words, serving the same food over days may result in a decreased desire to eat that food.
At the same time, giving oneself full permission to enjoy satisfying
meals and snacks may end the internal battle that plagues dieters. This is because dieters often try to “be good” earlier in the day and then throw
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in the towel in the evening, scouring the cupboards to satisfy a deprivation that’s been building all day. It’s the feelings of deprivation paired with guilt that make it hard to tune into internal cues such as hunger, fullness, and cravings, our only internal navigation that tells us what and how much to eat.
Many times, the client’s thoughts and worries about food disrupt this
internal navigation system. For example, if a client is preoccupied with the fat, carbohydrate, and calories in the chicken Alfredo she’s about to eat, she may completely miss that her body is actually craving a salad. The key is turning off the head game and listening to what the body wants and needs.
Human beings don’t just have cravings for fat, sugar, and salt. Humans are set up to crave the necessary nutrients that are lacking in the diet. Encouraging clients to tune into and trust their internal cues and cravings is a subtle way of supporting client autonomy within the process of change.
Habituation is not about encouraging a client to eat only chocolate
until she feels ill and repulsed by it. Instead, it’s about supporting your client in giving herself full permission to enjoy chocolate while tuning into how it makes her body feel. Using habituation techniques with previously forbidden foods ultimately alleviates the anxiety of food insecurity for a particular food and thus builds a healthier relationship with that food.
Chances are good that your client will crave a variety of foods once the internal food fight has ceased.
Many who struggle with compulsive eating will have a hard time
believing they can trust their hunger, fullness, and cravings. Clients will often say, “But I crave chocolate all the time! If I let myself eat it whenever I want it I’ll never eat anything else.” The client is really saying that she is afraid that she can’t be trusted with chocolate. As long as that belief is dominating her thoughts she can be expected to overeat it. But consider guiding the client in exploring her cravings
and the belief that’s fueling it. Use
Chances are good that your
open-ended questions and reflec-
client will crave a variety of
tions to point out the times of the day
foods once the internal food fight
when she doesn’t crave chocolate. For
has ceased.
example, she may not crave it first
thing in the morning when she’s lying
in bed. You might even be able to help her realize through a strategic summary that because she doesn’t allow herself to enjoy the chocolate while she’s eating it, her cravings are actually exacerbated by the feelings of guilt she experiences. If she comes to the realization that something needs to change, you can be there to offer information about the benefits of habituation and suggest an experiment at home.
A little nutrition knowledge can be helpful in guiding the planning of
balanced, satisfying meals, but a head full of nutrition rules and regulations could lead to a life of yo-yo dieting. Giving oneself full permission to enjoy
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favorite foods is a foreign concept and not a message a client expects to receive from her nutritionist. As with any change, baby steps may be necessary to get the client comfortable with enjoying feared foods in moderation.
Mindful eating
You can also help your clients by teaching them how to slow down the eating experience and to savor preferred foods. Eating mindfully takes practice. Each time your client pauses to check in with her cravings and body signals is a small victory on the path toward developing a healthy relationship with food. It’s important to celebrate these little victories by tuning your client into the small successes with affirmations.
How do you introduce mindful eating to clients? Start by having the
client talk about her craving. Have her pick one food that she feels most out of control around. Invite her to share how she’d like her relationship to be with that one food. Ask permission before giving information about habituation and mindful eating techniques, and check in to assess her response before moving forward, as in the dialogue below.
pRactitioneR: You shared that you feel out of control when you have
chips and salsa in the house. [reflection] What’s that like for you?
[open-ended question]
client: I open up a bag and a jar of salsa and it’s game over. I won’t
stop until the bag is empty.
pRactitioneR: You eat more than you’d like to eat. [reflection]
client: Yes, I’d like to eat like my boyfriend—help myself to 10 or 20
chips and move on. [change talk—desire to change]
pRactitioneR: He doesn’t seem preoccupied by the chips. [reflection]
client: No, it’s no big deal to him.
pRactitioneR: You’d like to no longer feel out of control around chips, more like your boyfriend. [reflection of change talk] Why do you
think he’s different with chips and salsa? [open-ended question]
client: I don’t know. There really aren’t any foods that he’s like that with. He doesn’t really have to watch his diet. He works construc-tion, so he’s always moving around at work and can eat whatever
he wants.
pRactitioneR: You’re wondering if the fact that he doesn’t diet has
something to do with his ability to control himself around chips
and salsa. [reflection] You might be on to something. [affirmation] Could I tell you about what the research says regarding diet-
ing and cravings? [asking permission]
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client: Sure.
pRactitioneR: Researchers are finding that when we tell ourselves we
can’t or shouldn’t eat certain foods, it may actually intensify the
craving. Som
e of my clients find that when they feel guilty after
eating the “forbidden” foods, they end up eating more because
they tell themselves they won’t be able to eat it again. [giving
information] What do you make of this information? [open-ended question]
client: Yes, I could see how that might be true. But what am I sup-
posed to do, though? Just eat them all the time?
pRactitioneR: I’m sure this may sound a little strange, but some of
my clients have found that giving themselves permission to eat
favorite foods when they crave them results in feeling less out of
control in the end. Eating chips and salsa around the clock might
get old after a while. I’m sure that’s hard to imagine. [giving infor-
mation] What would your week look like if you left here giving
yourself full permission to eat as many chips as you’d like? [open-
ended question]
client: Wow, that sounds a little scary. I’m pretty sure I’d pick some
up on my way home and eat them all. [sustain talk]
pRactitioneR: Yes, that sounds very likely, and it’s normal to feel
anxious about that. [reflection] What are you typically doing or
thinking while you are eating your chips and salsa? [open-ended
question]
client: Sometimes I’m chatting with my boyfriend, or watching TV.
I’m not sure.
pRactitioneR: It sounds like pairing chip-eating with TV and social-
izing enhances the experience. [reflection]
client: Yes, in a way, but sometimes I look down at the empty bag
and can hardly believe that I ate them all. I don’t even realize I’m
still eating them sometimes. [implying a desire to change]
pRactitioneR: You’re zoned out for much of the chip-eating experi-
ence and it’s like you’re missing the best part of your day. [com-
plex reflection – picking up on a desire to change]
client: I know. What’s the deal with that?
pRactitioneR: Would you be willing to try a little experiment? [ask-
ing permission]
client: Yes.
pRactitioneR: I’m curious what would happen if you gave yourself
full permission to eat as many chips and salsa as you wanted
from here until our next appointment and if at the same time you
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slowed down the eating experience and attempted to pay attention
to the taste and crunch of the chips and salsa while you are eating.
[posing a hypothetical experiment] What do you think might happen? [open-ended question]
client: I’d probably eat them for a few days, but I can see how I might get tired of them after a while. And I’d probably be really thirsty
from all the salt.
pRactitioneR: You’re noticing that your body may not feel so hot
on the chips and salsa diet and might start craving other things.
[reflection]
As in the dialogue above, take the client through some “what ifs” so
that she can envision the eating experience and talk through her fears and reservations of the experiment with someone she trusts. It’s also useful to explore the emotional component of eating. It may be that the chips and salsa are helping with a negative emotion. If she were to give herself full permission to eat the chips and remove distractions from her environment to eat mindfully, she may notice negative emotions such as loneliness, sadness, or anxiety start to surface.
As mentioned frequently throughout this book, food and emotions are
complex. For a client with binge-eating disorder, extensive therapy by a trained psychotherapist may be needed before a client can conduct a habituation eating exercise like this. (See Appendix 1, “Making Referrals.”) It’s important to assess your client’s history with behaviors such as restriction, binging, purging, and other forms of abuse. Furthermore, some clients may not have the luxury of eating whatever foods they want if dietary manipulation is a necessary therapy in the management or treatment of a disease or condition. For more resources on incorporating non-diet approaches into nutrition counseling sessions, visit Appendix 2, “Additional Resources.”
As with all nutritional changes addressed in this chapter, the spirit of MI serves as a guiding force. The following MI strategies are essential in behavior change counseling for dietary change:
• Invite the client to discuss current patterns and motivation for
change.
• Reflect and reinforce change talk.
• Ask permission before providing information about change and
deliver small bits of information at a time.
• Let the client take the lead in determining which changes she will
make and how she will make them.
It’s easy for change talk to be cloaked in ambivalence. Clients may
want to and know how to change, but need your help in moving through
their ambivalence toward change.
chAPter 14
Put ing Motivational Interviewing
to Work in Fitness Counseling
Don’t just add physical activity to your life, add life to your
physical activity.
—michelle may
The topic of fitness comes up often in health-based counseling. Many people lead sedentary lives, voicing inadequate time and resources for physical activity. For practitioners it may be all too tempting to discard the principles of MI and start giving directions based on the American College of Sports Medicine (ACSM) physical activity guidelines. Just as health professionals do their clients a disservice by directing them to “just eat less,” they equally disable them by saying, “just exercise more.” This chapter discusses the use of MI when discussing the topics commonly encountered in exercise counseling.
exPlorIng MotIvAtIon For PhysIcAl ActIvIty
Like with most behavior changes, motivation for physical activity is complex. Self-determination theory (SDT) brings to light common thoughts and attitudes clients experience when deciding whether or not to be active. SDT
is based on the idea that people are naturally self-motivated and eager to succeed because success in and of itself is gratifying and rewarding (Ryan
& Deci, 2000). According to the SDT, there are two types of motivation, known commonly as autonomous motivation and controlled motivation.
Autonomous motivation is present when the client finds the activity
enjoyable or discovers an immediate positive effect during and directly after exercising. In general, being active aligns with the client’s core values and he looks forward to the activity because of the intrinsic benefits and joy 212
MI in Fitness Counseling 213
of participating. Controlled motivation is the product of internal pressure that a client puts on himself to be physically active as well as any external reward for participating. Clients with controlled motivation may be motivated by competing in a sport to win, tracking activity using an exercise-tracking app or a wrist gadget, and often employ negative self-talk after missing days of activity. Although autonomous motivation is preferred,
both types of motivation have a place within an MI session.
Autonomous Motivation
Autonomous motivation is present when one is motivated by either the
inherent satisfaction of an activity or task or its alignment with his core values. If an individual is driven primarily by autonomous motivation then his motivation comes from within, absent from any outside pressure. Higher
amounts of this motivation are associated with an increase in sustained behavior change (Landry & Solmon, 2004).
An exerciser fueled by autonomous motivation may:
• Hit the gym because she knows that doing so will improve her over-
all mood and decrease the stress from a hard workday.
• Try to set a new personal record for pull-ups or lap times in the pool.
• Arrange a game of beach volleyball to enjoy time with friends in the warm sun.
• Make a goal to do something active each day of the week because he
feels sluggish, tired, and slightly depressed if he doesn’t.
• Sign up to run a race for charity because it gives her a personal goal and aligns with her values of health and serving others.
Exercise produces many potentially life-enhancing intrinsic benefits
and can easily be interesting and engaging. Joining a softball team after work, hiking on the weekends with friends, skiing, biking, dancing, and gardening are all examples of activities that exercise your body but are also fun and engaging.
There are more than 60 documented benefits to physical activity,
many of which are considered intrinsic. Physical activity has the potential to elevate your mood, reduce stress, and give you a sense of accomplishment. It can be fun and pleasurable no matter what effect it has on your physical appearance. Clients are often aware of the physical health benefits of exercise but are unaware of the intrinsic, mood-enhancing benefits. By tuning clients in to the immediate positive effects exercise can have on mental and emotional health, they may become more motivated to fit it into their busy lives. For example, when a client notices that riding her bike to work instead of driving actually puts her in a better mood when she gets home, she may be more likely to select this form of transportation. You can
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ask permission to communicate the intrinsic benefits of exercise with your clients in order to help them build habits that will stand the test of time.
To help clients shift focus to autonomous motivation, ask them how
being active aligns with their beliefs and values. Invite them to explore how they feel before, during, and
after exercising. Reflect and summa-
Reflect and summarize change
rize change talk that emphasizes the
talk that emphasizes the life-
Motivational Interviewing in Nutrition and Fitness Page 28