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Why the need for behavior change?
Having excess weight has contributed to a growing number of chronic diseases. We as coaches can help encourage our patients to talk about their goals rather than fixing the barriers to their eating behaviors or culinary behavior skills so that long-term change will be achieved. This module will focus on eliciting motivation and increasing capacity to change.
More about Motivational Interviewing
Motivational interviewing is a counseling technique that can be used to help clients recognize problems and then make informed decisions about whether or not they want to work on change. It is a client-centered technique that guides elicit individuals to identify reasons that will strengthen their personal motivation toward change. One of the goals is to assist clients to work through their ambivalence or resistance about behavior change. It is effective for individuals who are initially resistant to change. There are two sources of motivation, one is the external motivation (most likely driven to please another or get the person’s approval or respect or monetary) and the autonomous motivation. When the client is autonomously motivated, these are associated with long term change because they are satisfying in their own right. Three fundamental human needs that are relevant of motivating behavior change includes, competence, relatedness and autonomy. Competence describes the client’s confidence in their ability to undergo change. Building self-efficacy for change is a core concept of MI as reflected by the 0-10 confidence ruler.
Coaches should help clients develop realistic goals that would build efficacy and encourage persistence. Relatedness involves uncovering a client’s reason for change (evoking). Exploring the big “WHY” behind the behavior change can create the energy needed for a shift. Coaches help clients discover their purpose behind any desired change. Knowing one’s meaning and purpose is necessary of healing, resilience, optimism and well-being.
Coaches should help clients develop realistic goals that would build efficacy and encourage persistence. Relatedness involves uncovering a client’s reason for change (evoking). Exploring the big “WHY” behind the behavior change can create the energy needed for a shift. Coaches help clients discover their purpose behind any desired change. Knowing one’s meaning and purpose is necessary of healing, resilience, optimism and well-being.
Basic Skills in Motivational Interviewing
Open-ended questions
This gives the clients opportunity to talk and share their views that and through this can affirm change talk and encourage patients to take positive steps toward their health goals in promoting lifestyle change.
Affirmations
Affirmations are positive reminders or statements coming from a coach or a person that can be used to encourage and motivate yourself or others. It is often easier to affirm others than it is ourselves.
Reflective listening
Reflective listening the the core component of client-centered counseling.
“If I heard you correctly, this is what I think you are saying…
“You are having trouble with..
Goal: to demonstrate that the coach is listening intently and is trying to understand what the client has said, affirming the client’s thoughts and feelings without judgement and helping them in their self-discovery. This may clarify the clients’ thoughts and feelings and may correct the inaccuracy the coach’s view of that the client had said. This is a great way to build rapport and show compassion. We should prevent giving advise or ask questions that can be biased. Reflecting helps ensure that the direction of the encounter is still client-driven. There area three broad types of reflection: reflection of content, feeling and meaning.
Content: repeating back to clients a version of what you have been told.
Client: “I want to start eating healthy again.”
Coach: “You want to start eating healthy again.” Or
“Eating healthy is very important to you.”
A client may say, “Yeah, I don’t have time to prepare healthy meals. just no way.” “It sounds like what you are saying is you don’t have time to cook at home.” Then the patient repeats, “Right, I have no time to time to cook. The coach could reply, “there is absolutely no way you could possibly cook in any say this week or next week or any week in the near future.” The patient could respond to this with, “It’s not that, I just said I don’t have time to cook. I might have time in a week or two.” At this point the client is explaining that he/she might actually have time to cook. Reflecting not only shows patients that coaches are listening, it also allows for an opportunity to evoke change talk.
Emotions:
Client: “If I don’t stop eating processed meat, I won’t be able to control my blood pressure and blood sugar, and I might suffer stroke/heart attack and die.”
Coach: “You’re worried that your eating of processed food is a matter of life and death for you.”
Meaning:
reflecting a client’s meaning can increase the client’s self-awareness while encouraging emotional depth in the session.
Summarizing
This approach will assure the clients that their coaches have been listening to them for the entire session. Summarize statement to the client and check in to see if the client agrees with what you have observed, heard and thought during the session. Example: “Lea, I could tell that you have been very frustrated with your weight loss journey. You have had tried different weight loss programs and failed. It sounds to me like you are willing to work on losing weight again but is not sure how to go about it this time. Is there anything else you would like to add to what I just shared?”
Once the summary is confirmed with the client, propose what the focus of the next session will be or consider assigning homework for the client to do before the next session. Example: “Lea, it sounds like we need to talk further about how we can work on you losing that excess weight. Possibly next time we can discuss what went well in the past when you lost 5-lbs? Before our next session, would you be willing to write down what you felt when you began losing weight, and how you were able to lose 5-lbs in 1 month?” Check in to see if the client is amenable to it.
Listen carefully to how the client responds when you summarize and make a connection of what you heard the client said and observed during the session.
This gives the clients opportunity to talk and share their views that and through this can affirm change talk and encourage patients to take positive steps toward their health goals in promoting lifestyle change.
Affirmations
Affirmations are positive reminders or statements coming from a coach or a person that can be used to encourage and motivate yourself or others. It is often easier to affirm others than it is ourselves.
Reflective listening
Reflective listening the the core component of client-centered counseling.
“If I heard you correctly, this is what I think you are saying…
“You are having trouble with..
Goal: to demonstrate that the coach is listening intently and is trying to understand what the client has said, affirming the client’s thoughts and feelings without judgement and helping them in their self-discovery. This may clarify the clients’ thoughts and feelings and may correct the inaccuracy the coach’s view of that the client had said. This is a great way to build rapport and show compassion. We should prevent giving advise or ask questions that can be biased. Reflecting helps ensure that the direction of the encounter is still client-driven. There area three broad types of reflection: reflection of content, feeling and meaning.
Content: repeating back to clients a version of what you have been told.
Client: “I want to start eating healthy again.”
Coach: “You want to start eating healthy again.” Or
“Eating healthy is very important to you.”
A client may say, “Yeah, I don’t have time to prepare healthy meals. just no way.” “It sounds like what you are saying is you don’t have time to cook at home.” Then the patient repeats, “Right, I have no time to time to cook. The coach could reply, “there is absolutely no way you could possibly cook in any say this week or next week or any week in the near future.” The patient could respond to this with, “It’s not that, I just said I don’t have time to cook. I might have time in a week or two.” At this point the client is explaining that he/she might actually have time to cook. Reflecting not only shows patients that coaches are listening, it also allows for an opportunity to evoke change talk.
Emotions:
Client: “If I don’t stop eating processed meat, I won’t be able to control my blood pressure and blood sugar, and I might suffer stroke/heart attack and die.”
Coach: “You’re worried that your eating of processed food is a matter of life and death for you.”
Meaning:
reflecting a client’s meaning can increase the client’s self-awareness while encouraging emotional depth in the session.
Summarizing
This approach will assure the clients that their coaches have been listening to them for the entire session. Summarize statement to the client and check in to see if the client agrees with what you have observed, heard and thought during the session. Example: “Lea, I could tell that you have been very frustrated with your weight loss journey. You have had tried different weight loss programs and failed. It sounds to me like you are willing to work on losing weight again but is not sure how to go about it this time. Is there anything else you would like to add to what I just shared?”
Once the summary is confirmed with the client, propose what the focus of the next session will be or consider assigning homework for the client to do before the next session. Example: “Lea, it sounds like we need to talk further about how we can work on you losing that excess weight. Possibly next time we can discuss what went well in the past when you lost 5-lbs? Before our next session, would you be willing to write down what you felt when you began losing weight, and how you were able to lose 5-lbs in 1 month?” Check in to see if the client is amenable to it.
Listen carefully to how the client responds when you summarize and make a connection of what you heard the client said and observed during the session.
Motivational Interviewing and TTMC
MI is closely associated with the transtheoretical Model of Change (TTMC) wherein individuals progress through these stages of change:
- Pre-contemplation
- Contemplation
- Preparation
- Action
- Maintenance
Case:
Mrs Lea is 55 year old, a known hypertensive, obese with a BMI of 32 and a waist-hip-ratio of 0.95, with glucose intolerance. You saw her in your clinic with BP of 128/82 and HBa1c of 7.0% (Diabetic level). She has gained three pounds over the last 3 months and seven pounds over the last year. She is fond of eating out and loves to try out new restaurants. She has been aware of her weight gain noticed by the tightening of her clothes.
Mrs Lea is 55 year old, a known hypertensive, obese with a BMI of 32 and a waist-hip-ratio of 0.95, with glucose intolerance. You saw her in your clinic with BP of 128/82 and HBa1c of 7.0% (Diabetic level). She has gained three pounds over the last 3 months and seven pounds over the last year. She is fond of eating out and loves to try out new restaurants. She has been aware of her weight gain noticed by the tightening of her clothes.
Coach: “Hi, Mrs. Lea! It is goof to see you!”
Mrs. L: Good to see you too, coach.
Coach: “would it be okey if we talked about your increasing BMI?”
Mrs. L: “Sure coach, what about it?”
Coach: “I have noticed your BMI has increased since your last record from another physician and you mentioned you eat out a lot. Do you think eating out has something to do with your weight gain?”
Mrs. L: “I don’t think so coach, I don’t eat much when I eat out and when I am out, I get to try new dishes and it relaxes me. It is my reward for myself.” (Precontemplation)
Precontemplation stage include establishing rapport with the client and creating a supportive environment, and assessing the client’s motivation, nutrition knowledge, beliefs, thoughts, fears, and physical and nutritional status. The most important activity to do with clients at this stage is to explore the costs and benefits of changing.
Coach: “Do you know that restaurants have higher caloric content, more salt and sugar content too than home cooked foods?”
Mrs. L: “Tell me more about it. What do I need to do? Is there a way to help me cut back on calories? I used to cook at home and I miss doing that.
Coach: “Oh yes! Your husband mentioned that you were such a good cook, tell me, what were your favorite dishes to cook? ”
Mrs. L: “I used to accept orders for parties of family and friends, they all loved my cooking. But since I had been in the corporate world, it is easier to eat out than cook at home. I miss cooking at home and at the same time, I love eating out.” (Contemplation)
In the contemplation stage, we can help the client by prioritizing and discussing eating behaviors to change. Identifying barriers and exploring coping strategies, discussing food records, identifying client’s support system, and reviewing what the client should expect physically and psychologically as she changes her eating behavior.
Coach: “what would your life be more like if you have lost some weight?”
Mrs. L: “I look forward to that day that I will began losing weight. I can fit in my clothes and I will be able to move with ease without going out of breath.”
Coach: “What will be motivate you to reach your goal (weight loss)?”
Mrs. L: “I am now enrolled to a gym and I have been working out regularly, but I guess my eating out has contributed to my weight gain and unhealthy eating. I guess I will go back to cooking at home so I could have healthier choices. Can you share with me recipes I could use? I will go to the grocery store to shop fresh produce tonight on our way home.” (preparation)
Coach: “Sure, I have them here. Can you go over the recipe and if you need any help, I can assist you. You may call/text me at… Is next week good for you for your follow-up visit?”
Mrs. L: “Yes, I really appreciate this recipe that you have shared with me. I will try this at home tonight. I will see you next week then. Thank you so much.”
In the action stage, we can reinforce the client’s self-confidence and encourage more movement toward healthy eating. Teaching the client behavioral strategies and helping her to increase her sense of self-efficacy is very important at this stage.
Relapse stage
Clients may revert to an earlier stage of change and when this happens explore what is going on in the client’s life like stressors, or memory, etc. In the last 2 months you were home cooking your meals and you are now back to eating out. It makes me wonder if something else is going on that is causing to not cook at home.
We can go back to our notes (it is really good for our clients to write down the reasons she wants to eat healthier, and to keep a copy) and remind our client of what she/he wrote for his/her reasons for changing and challenge the client on what’s different now.
Supplemental Materials
Video Review
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Unit Task
- Task 1: Submit your Reflective Journal after watching the videos, reading the lesson and article.
- Task 2: Look for a patient/client who is a good subject for coaching and apply the motivational interviewing skills you learned from the this unit. Create a summary on what transpired on your MI session.