Motivational interviewing – helping patients to change

Motivational interviewing is a collaborative, person-centred form of guiding to elicit and strengthen motivation for change.¹ Clients come to registered dietitians looking to change habits so dietitians need to have the skills to listen and evoke change. 

With the client at the centre, dietitians can understand their story, assess readiness to change and empower them by giving the freedom to make their own decisions. If we do not use a process involving motivational interviewing, it is unlikely that our clients will achieve long-term changes. For if we tell them what to do, they will resist change. Our job really is to clarify, direct and support the client as he or she works towards identifying small and simple changes that will promote weight loss.

Structured questions

In order to focus on what is important for the client, a series of structured questions need to be asked during the consultation to help the client to consider, motivate and commit to change.² Types of questions to ask include:

• Open questions, the answers to which are likely to promote change 

• Explore decisional balance: Ask for the pros and cons of both changing and staying the same

• Ask about the positives and negatives of the target behaviour

• Ask for elaboration or examples: When a theme emerges ask for more details, eg. ‘in what way’ or ‘tell me more about that’

• Look back, ask about the last time a target behaviour emerged: How are things better or different now?

• Look forward: Ask what may happen if things continue as they are. Ask the question ‘if you were 100% successful in changing, what would be different?’

• Query extremes: What are the worst things that might happen if you don’t change? What are the best things that might happen if you do change? 

• Use change rulers: Ask ‘on a scale of one to 10, how important is it to change the specific target behaviour?’ (One is not important and 10 is extremely important). Follow up with ‘and why are you at number___ and not ___?’, ‘What might happen that could move you up a number?’

• Explore goals and values: What does the client want in life and does losing weight fit into this goal and value? 

• Come alongside: Side with the negative side of ambivalence, eg. perhaps losing weight is so important to you that you won’t give up, no matter what the cost?

Stages of change

Discussing the stages of the change model³ (see Figure 1) will help assess their readiness to adopt new, healthy behaviours. Discussing the stages of change will also help because:

 (click to enlarge)

• Clients feel comforted knowing that it is ok to resist changing habits and that this does not mean they are destined to fail

• Clients understand that they do not have to make a lot of changes in one go, but that making small realistic changes is still progress

The practice of motivational interviewing cannot work without the structure of OARS – open-ended questions, affirmations, reflective listening and summarising. It is how you ask the questions that matters.

Questioning skills

A question with a ‘why’ in it implies that the client should do something. For example ‘why don’t you bring your lunch to work?’ This can cause resistance on the client’s part. 

Changing the tone of the question by using ‘what’ or ‘how’ softens the tone, eg. ‘what keeps you from taking your lunch to work’ or ‘how would things have to change for you to bring your lunch to work?’ – this implies the situation can be changed. 

Poor questioning skills can have a very negative impact on your client, making them dwell on what went wrong, eg.  instead of phrasing a question like ‘why do you think you ate those cookies late at night?’, try saying ‘what can you try differently when you’re hungry at 9pm?’ to help to prompt a solution.  

Don’t use ‘queggestions’ which are suggestions posing as questions, eg. ‘what if you make your lunch the night before?’ – this is an idea that may work for you as the dietitian, but not necessarily for the client.  Giving clients the opportunity to think of the answer themselves, helps them to find what works for them and helps them to form their own solid plan.

Never underestimate the power of expressing empathy during tough spots or in celebrating patients’ accomplishments. When you review patients’ goals, take delight in their success and show your joy. 

Learn to listen

As dietitians, it is built within us to automatically explain and advise, but if we rush in and correct and tell clients what to do, we quickly ruin the chance of understanding the real problem. Practise entering a dietetic consultation without an agenda. Try not to anticipate what a client needs before they are finished talking and avoid giving an immediate solution, which actually would mean that you have stopped listening. 

Reflecting on patients’ statements and feelings back to them reinforces self-efficacy, allowing conversation to keep moving forward and showing empathy along the way.

At some point, dietitians will likely need to give advice to a client, but keep in mind, it is how you give that advice that will be key in preventing clients feeling as though they are doing something wrong. Try to be more objective so that clients almost feel as though they have come up with the idea themselves, eg. ‘how might it benefit you to keep a food diary before you decide not to?’ or ‘would it help if I explained why breakfast is so important to help change your mind about skipping breakfast?’. Clients will feel respected when dietitians ask permission to give advice, plus they feel in control.

Before the end of a consultation it is useful to recap on what the client has said and clear up misunderstandings. Often it can be useful to ask a client the following:

• What they have learned

• What they have realised

• What they plan to change or work on over the next week or two

These questions are also a good way of assessing how much information they have gathered. Practise listening and advising during daily interactions with friends and family and see how sitting in the navigator’s seat can still keep clients on track. 

How do I get started with motivational interviewing:

• Start small with a few of the key questions from the first one to 10 questions 

• Using open-ended questions will help to keep the conversation flowing 

• Bring your own spirit to the consultation. Do not be afraid of saying the wrong thing, clients will sense your good rapport. 

Motivational interviewing will become more natural to you after a few consultations and you might find it actually helps to ‘free you up’. A few good courses and books are mentioned below to help you on your way.

Recommended courses

• NICP motivational interviewing course; levels one to three with Irene Gibson, Croi 

• Behaviour change training, levels one to three with Dympna Pearson, registered dietitian.

Recommended books

• Motivational Interviewing: Helping People Change by William R Miller

• Weight Management: A Practitioner’s Guide by Dympna Pearson and Clare Grace.

The mindful eating approach

Being mindful of why, where, when, what and how much we eat helps people notice their direct experiences and behaviours. The Mindful Eating Cycle⁴ (see Figure 2) developed by US dietitian Michelle May is a good tool for clients to help increase awareness and change actions. The elements of the Mindful Eating Cycle include:

 (click to enlarge)

• Why do I eat? – explores triggers like physical hunger, challenging situations which often spring from stress, fatigue or boredom

• When do I want to eat? – this can depend on the time of day, physical hunger cues or emotions

• How do I eat? – is eating a rushed, mindful, distracted or secretive process?

• How much do I eat? – quantity can be decided by physical fullness cues, portion size or habit

• Where does the energy go? – eating can be mood boosting, cause sluggishness, lead to guilt/shame. How is the energy used in work versus the home setting?

Clients can be encouraged to ask themselves the above questions to help increase their awareness and prompt change. Simply getting clients to ask themselves multiple times a day ‘am I actually hungry?’ might help to put a pause between the trigger and the response. 

By helping clients become the expert on themselves in their weight loss journey, and with effective listening, dietitians can help them feel that the real source of the problem is being understood.  

Some dietitians may wonder how can they be sure that motivational interviewing is working. Signs that it is working include:

• When the client is doing more talking during the consultation 

• When you as the dietitian are speaking more slowly yet doing less of the talking and offering empathy and listening carefully 

• When the client appears to be working hard to think about their issues and a solution to their issues 

• When the client is asking for information and advice rather than the dietitian just handing out advice.

References

1. Miller,W.R.& Rollnick,S.(2009). Ten things that Motivational Interviewing is not. Behavioural and Cognitive Psychotherapy,37,129F140
2. Lussier MT & Richard C (2007). The motivational Interview.  Can. Fam. Physician 53 (12): 2117-2118
3. Prochaska J and DiClemente C (1983).  Stages and processes of self-change in smoking: toward an integrative model of change.  J. Consulting and Clinical Psychology 5, 390-395
4. Eat What You Love Love What You Eat: How to Break Your Eat-Repent-Repeat Cycle. May M.  Greenleaf Bookgroup Press; 2010.