Motivational Interviewing in Nutrition and Fitness
Page 34
else? [open-ended question]
Client: I feel bloated. I definitely don’t feel like jumping up and doing something after dinner. And then I feel even worse.
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MI IN NUTRITION AND FITNESS INDUSTRIES
pRactitioneR: There’s possibly some guilt and shame mixed up in
these overeating experiences. [complex reflection]
client: And then, sometimes, I eat even more because I feel like I’ve
blown it so I might as well get some more in before I start over
again the next day.
pRactitioneR: This desire for weight loss comes up for you and in a
lot of ways makes things worse. [complex reflection]
client: Yeah, it does!
pRactitioneR: You’re ready to try something different. [reflection
that takes a guess at change talk]
client: Yes, I am. I’m stuck in this vicious cycle. [change talk—activation]
pRactitioneR: You’re ready to break the cycle by slowing down and
starting to experience satisfaction while you eat instead of racing
to the end. [reflection of change talk]
client: Yes.
pRactitioneR: What might you do to remember to slow your pace
during your meal? [open-ended question—key question]
In this dialogue, the practitioner uses the focusing process to guide the client toward a specific behavior change within the broad topic of intuitive eating. The practitioner then guides the client into the evoking process with the purpose of eliciting change talk. The script ends with a key question (Chapter 4) to transition the client to the planning process where specific strategies can begin to take shape.
Principle 5: life-enhancing Movement
The final HAES principle is centered on supporting “physical activities that allow people of all sizes, abilities, and interests to engage in enjoyable movement, to the degree that they choose.”
Dieters often start exercising with the intention of losing weight. Motivation is strong at first, but often wanes as soon as weight plateaus. Furthermore, exercising with a mindset of calories burned can rob the dieter of the joy that is possible with physical activity. When weight loss is the goal, both food and exercise can become drab and unappealing. In a nondiet approach, food and physical activities are selected mindfully based on enjoyment and pleasure. Exercise is no longer viewed as a way to be able to eat more, but as a fun pastime that feels good.
When using a non-diet approach to physical activity, clients are invited to brainstorm the activities they enjoy most. At the same time, clients are exposed to the intrinsic benefits of exercise such as improved sleep, improved body image (regardless of changes in weight), enhanced feelings
MI to Address Weight Concerns and Disordered Eating 249
of physical hunger, and reduced stress, depression, and anxiety. Clients explore their attitudes about exercise and are asked to voice the immediate psychosocial benefits they often experience when they are active. Coaching a client toward mindfulness involves attending to how the body feels while exercising and tuning in to positive and negative attitudes that may arise.
Through tuning clients in to individual body cues, clients learn to
pay attention to the various emotional components of eating and activity.
Instead of encouraging clients to accept themselves only after the weight has been lost, clients are invited to begin the journey toward a positive body image regardless of size and shape.
As demonstrated throughout this chapter, the spirit of MI can be used
as a guide to address your clients’ weight concerns. Figure 15.3 summarizes the similarities between the MI spirit and non-diet approaches. Additional resources on adopting non-diet approaches such as the HAES paradigm
can be found in Appendix 2, “Additional Resources.”
While focusing on weight and body composition may motivate cli-
ents to make positive eating and activity changes at first, motivation will be short lived if weight doesn’t continue to drop. Sustainable change is achieved when the process of eating and being active is rewarding and
enjoyable. Typically, calorie-restricted eating plans and tedious physical activity regimens are far from enjoyable, especially when clients don’t see their expectations being met. Helping clients tune in to the moment-tomoment benefits (or intrinsic benefits) of behavior change fuels changes that will last a lifetime.
Spirit of MI
Strategies for addressing clients’ weight concerns
Partnership
Treat the client as the expert of his or her body.
Acceptance
Avoid using judgment, shame, or fear as a motivator for
behavior change.
Absolute worth
Avoid discrimination, stigmatization, weight bias, and making
assumptions.
Accurate empathy
Attempt to see the world through the eyes of clients who
experience oppression and stigmatization.
Autonomy support
Give client freedom of choice with food, fitness, and self-care.
Affirmation
Provide affirmations based on changes in attitudes, personal
discoveries, and behaviors, not outcomes.
Compassion
Commit to the overall wel -being of the client instead of self-
gain.
Evocation
Evoke negative aspects of dieting as well as change talk in
support of whole-body self-care.
FIgure 15.3. The spirit of MI as a guide in addressing clients’ weight concerns.
APPendIx 1
Making Referrals
Food and nutrition is a complex topic that easily bleeds into other issues. Popular author on compulsive eating and dieting Geneen Roth (2010) states, “The relationship with food is only a microcosm for your relationship to the rest of your life.” Therefore, nutrition counselors often find themselves discussing topics that they aren’t formally trained to discuss, such as parenting, communicating with family members, drugs and alcohol, and body image.
The framework that describes this circle of knowledge and skills is known as one’s scope of practice. For example, the Scope of Practice in Nutrition and Dietetics encompasses the range of roles, activities, and regulations within which nutrition and dietetics practitioners perform (Academy Quality Management Committee and Scope of Practice Subcommittee of the Quality Management Committee, 2013b). Be sure to investigate both the rigid and flexible boundaries that make up your personal scope of practice. A dietitian’s individual scope of practice has flexible boundaries based on personal education, training, credentialing, and demonstrated and documented competence.
Boundaries that are more rigid include professional codes, laws, and hospital and clinic policies.
Within every profession, skill sets and level of expertise can expand with training and experience. For example, a new fitness instructor may feel uncomfortable talking about sports nutrition with a client if she received very little training in this area during her education and training programs. However, if the fitness instructor takes a semester-long sports nutrition course as an elective in graduate school, her scope of practice would expand, assuming that tackling these issues wouldn’t go against any institutional policies or governing rules and regulations. The scenarios outlined in this book cover a wide scope of practice and are not intended to encourage people to practice outside their lawful business code or code of ethics.
Nutrition and fitness practitioners are at risk for crossing the line into a number of other disciplines, including pharmacy, medicine, addictions counseling, social work, and psychotherapy. One common source of discomfort 251
252
Appendix 1: Making Referrals
among nutrition and fitness practitioners is the fuzzy line between behavior change counseling and psychotherapy. The goals of nutrition and fitness counseling a
nd psychotherapy are very different. Counseling performed by a nutritionist or fitness expert typically centers around changing a food or exercise behavior. In psychotherapy, the treatment goals are focused on managing mental illness, mood, emotional healing, and improving relationships.
It is important to remain mindful of your scope of practice. Some signs that you are practicing outside of your scope of practice include:
• A significant amount of the session is on topics unrelated to nutrition and food.
• You have a gut feeling of discomfort or anxiety during a counseling
session.
• You get the feeling you may be stepping on the toes of another health care professional.
• You are spending a lot of extra time coordinating care for the client because they could use help “navigating the system.”
There are many costs involved with stepping outside of your scope of practice. First, stepping outside of your scope could offend another practitioner.
Worse, you could harm a vulnerable client. You can also set yourself up for burnout. It’s important to speak up when you notice that a client is struggling with an issue that warrants care from another professional.
reFerrIng clIents to MentAl heAlth ProFessIonAls
Unfortunately, there is some stigma surrounding seeing a mental health professional. Making matters worse, clients are sometimes afraid of talking about their difficult and emotional life trials. Often the nutrition counselor is sought first and seen as less stigmatizing and safer. The client may not be aware of the underlying issues driving her behavioral choices and make an appointment with a nutrition counselor thinking that gaining nutritional knowledge will suffice. Being that there are many complex underlying issues surrounding food and body image, clients’ needs are often beyond the scope of a nutrition therapist. Providing a referral to a psychotherapist can be challenging and intimidating to some nutritionists. However, you would never send a broken-down automobile to a motorcycle mechanic, right? It’s important to get clients the specialized care they need.
Here are a few signs that your client may benefit from seeing a psycho-
therapist:
• A heightened concern about body weight or body image, as evidenced
by regular weighing; body-bashing language; compensatory behaviors
Appendix 1: Making Referrals 253
such as vomiting, excessive exercise, diet pill, or laxative abuse; and mood shifts related to weight fluctuations.
• Mention of abuse from others, including physical, sexual, or verbal
abuse.
• Marital stress.
• Parenting challenges.
• Loss/grief.
• Emotional states such as sadness, anxiety, depression, hopelessness.
• Suicidal ideation.
• Posttraumatic stress from a previous event.
When making a referral, nutrition therapist and MI expert Molly Kellogg (2009) recommends first providing a reflection or summary that highlights the areas of concern. Next, describe the benefit of meeting with the therapist. In true MI fashion, ask for the client’s thoughts on meeting with another professional and finally ask permission before providing names of therapists. These four steps are summarized in Figure A.1 and examples of common referral topics are provided.
When providing referrals, avoid making mental health diagnoses or labeling clients or therapists. For example, which of the following may be better received by a client?
“Your symptoms are consistent with an eating disorder. Would you like to see an eating disorder specialist?”
“You’re concerned about how much time you spend thinking about food
and weight. Would you like to see someone who specializes in thought
patterns surrounding food and body image?”
By avoiding the label of eating disorder, there may be less resistance to seeing the specialist. As the nutrition counselor, you choose whether to make the referral, you control the wording used in communicating this to the client, and you can document that the referral was made. However, you are not in control of whether the client follows through with the referral.
Consistent with the spirit of MI, give the client complete autonomy to follow through with the referral. That does not always mean you must continue to see this client. For example, due to issues with liability and standards of good care, most dietitians refuse to see clients with eating disorders unless the client is also seeing a therapist and physician. While this may seem inconsistent with autonomy, if this policy is clearly communicated to the client, the client still decides whether she will continue with services. You might explain this to the client by stating, “It works best when my clients work with a team that includes a doctor, a therapist, and a dietitian. I want the very best care for you, so I’d be glad to work with you as part of your team, but not alone.”
Psychotherapists have specialty areas. Keep a list of therapists in your area
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Appendix 1: Making Referrals
Example C:
Example a:
Example B:
Emotional
Example D:
Marital conflict
Eating disorder eating
Parenting issues
Step 1: Reflect “Last session
“It sounds like
“You shared
“You’re concerned
what you hear.
you shared that
you’re thinking that anxiety
that your son’s
you were having
about food and is something
behavior at the
a hard time
body more than you struggle
dinner table
communicating
you’d like to be. with and you’re is negatively
your needs with
You’ve given a
noticing how
affecting the eating
your husband.”
few examples
stress and
experience for the
of how those
anxiety prompt entire family. You
thoughts have
you to eat
feel stuck and are
interfered with when you’re
hoping to get more
different areas
not necessarily ideas about how
of your life.”
hungry.”
to set up clear
boundaries and
rules at the table.”
Step 2: Explain “I wonder if it
“To move
“I know there
“You’re not alone.
how a therapist might be helpful
forward in
are a lot of
Parenting is hard
may be able to to discuss these
reducing these options for
work. There are
help.
challenges with
thoughts, many managing
some wel -trained
someone who
of my clients
anxiety. I’m not marriage and family
specializes in
have found
an expert in
therapists in town
relationships and it useful to
that area, but
who have helped
communication.”
meet with a
I know others
other clients of mine
counselor who
who are.”
figure out solutions
specializes in
for these types of
helping clients
scenarios.”
navigate this
internal battle.”
Step 3: Ask
“What do you
“How do you
“What are your “What are your
what the client
think about
feel about
thoughts about thoughts on meeting
thinks.
meeting with
meeting with a seeking further with someone
someone who
therapist who
assistance
who can help you
could give you
specializes in
in managing
explore these and
some ideas
food, mood,
your anxiety
other parenting
about opening
and body
with someone
challenges?”
up the lines of
image?”
trained in that
communication in
area?”
your marriage?”
Step 4: Ask
“Would you be interested in some names and phone numbers of some of the permission and experts in our area?”
provide contact
information.
FIgure A1. Four steps to providing a referral.
Appendix 1: Making Referrals 255
along with their specialties. Build relationships with these mental health professionals and communicate about referral topics and strategies. Experienced nutrition and fitness practitioners know their place as a member of the health care team. As you gain additional training through continuing education, regularly reassess your individual scope of practice and the scope of practice of professionals in your area. Health care is a team approach and nutrition and fitness professionals, armed with MI, are valuable team members.
APPendIx 2
Additional Resources
This book serves as a diving board with the hope that you will bounce off and out into the water of nutrition and fitness counseling attempting some of these skills. Just as you can’t simply read a book about how to swim and assume you will glide through the water, mastering MI requires practice, supervision, and feedback. Here are some additional resources to assist you in your MI journey.
resources on MotIvAtIonAl IntervIewIng
Books
Miller, W. M., & Rollnick, S. (2013). Motivational interviewing (3rd ed.) : Helping people change. New York: Guilford Press.—Miller and Rollnick are the developers of MI and this is their third edition. The book provides a thorough overview of MI with sample scripts covering a wide variety of disciplines.
Wagner, C. C., & Ingersoll, K. S. (2012). Motivational interviewing in groups.