Motivational Interviewing (MI) =
Basic principles
collaborative, person-centered form of guiding to elicit/strengthen motivation for change.
Focus on intrinsic motivation, originating from internal beliefs and values.
Basic Principles:
Resist the righting reflex
Understand your client’s motivation
Listen to your client
Empower your client
Tailored nutrition counseling =
Client-centered approach =
Tailored nutrition counseling = allows exploration and resolution of ambivalence in dietary changes. Effective for weight management
Client-centered approach: empathy and understanding to see the situation from a client’s perspective.
Spirit of MI (PACE)
Partnership of equals → collaboration with clients
Partnership vs directive approach
Acceptance → showing empathy and respecting patient’s autonomy
Acceptance vs judgement
Compassion → offering support with understanding and care
Compassion vs detachment
Evocation → drawing out client’s own reason for
change, use their wisdom
Evocation vs instruction
4 processes of MI
Engage: establish partnership
Focus: clarify their agenda
Evoke: elicit reasons for change
Plan: commit to a plan of action
Core skills of MI
Open-ended questions: encourage clients to express themselves freely
Affirmations: recognize and validate client’s strengths, efforts and achievements to boost their confidence
Reflective listening: demonstrate active listening by echoing client’s statements, showing empathy and understanding
Summarizing: consolidate and reinforce key points from the conversation, helping to clarify client’s motivations and plans
Evoking change talk DARN CAT
Desire → expressing wanting to make a change
Ability → mention of capability to change
Reasons → provision of reasons/arguments why change is beneficial
Need → urgency or necessity/obligation of change
Commitment → stating intention to act (varying levels of commitment)
Action taken → statements about action taken
Take steps → taking concrete actions toward change
Ambivalence =
Why are people ambivalent?
Ambivalence: state of having mixed feelings or contradictory ideas about change.
Contemplation/preparation stages of change
Alternatives are equally appealing
Neither course of action is appealing
Conflicting feelings, fear of loss, not knowing what’s right.
Change talk vs sustain talk
Change Talk: statements made by the client that indicate they are considering or are already motivated for change. Statements often reflect a desire, ability, reason or need.
Sustain Talk: statements made by the client that indicate reasons for maintaining their current behaviors or resisting change. Typically reflects the client’s ambivalence. Key aspects include:
Desire to maintain status quo
Ability doubts
Reasons for not changing
Need to avoid change → expressing no need to change
Handling resistance: techniques include
Reflective listening → acknowledge concerns without judgment
Reframing → shift perspective to focus on gains
Rolling with resistance → avoid arguing/confrontation, let client express resistance while maintaining collaborative stance
Decisional balance, exploring discrepancies and evocative statements
Decisional Balance: purpose is to explore both pro’s and con’s on making change, encouraging the client to articulate reasons for change.
Exploring Discrepancies: highlight the difference between the client’s current behavior and their long-term goals, helping them to see the need for change.
Evocative Statements: encourage the client to elaborate on their reasons for change by prompting them to reflect on their goals and values
Strategies to evoke/elicit Change Talk
Ask evocative questions → open-ended, exploration of thoughts and feelings
Explore decisional balance
Talk about good things/not so good things (positives and negatives of target behavior)
Ask for elaboration/example
Look back → how things were before the current situation
Look forward → ask to describe hopes and goals for future
Query extremes → “what is the worst/best thing that might happen?”
Use scaling → assess readiness, confidence or importance of change with 0-10, then “why did you choose that number and not 0?”.
Explore goals and values
Come alongside
Culture vs race vs ethnicity
Culture = how people define themselves via shared beliefs, food, traditions, arts, rituals, values, customs, communication styles and practices
Race = group of people with biologically similar skin or facial characteristics
Ethnicity = shared components of race, language, customs, religion based on cultural characteristics
Influences on cross-cultural communication
Influences: race, gender, age, nationality, socioeconomic status, religion, educational background, sexual orientation and political affiliation
Culturally competent communication includes:
Willingness to listen and learn
Appropriate provision of services/information (language, literacy)
Awareness of one’s own biases and develop cultural humility
Develop an understanding of diverse world views
Ask open-ended questions to investigate their perception/definitions of situation
Learning greeting words, sleep slowly at a normal volume
Build on positive aspects of current nutrition practices
The right to an interpreter
ETHNIC or LEARN model of culturally sensitive communication
ETHNIC model: Explanation, Treatment (ex. Home remedies), Healers (other advice sought), Negotiate, Intervention, Collaborate
Or
LEARN Model: Listen, Explain (reflect), Acknowledge, Recommend, Negotiate
Guidelines for Working with Interpreters
Beginning:
Allow for extra time
Introduce all parties and invite interpreter to sit next to you
Invite client to look at dietitian while interpreter speaks
Insist on direct interpretation
During:
Use 1 simple, short phrases at a time and avoid jargon
Speak directly to client
Request time outs to clarify issues
Watch non-verbal communication of unease
Confirm understanding by asking client to repeat messages back
Voyce translator app for medical interpretation if no translator available
Bias =
Strategies to avoid bias
BIas = tendency to favor one explanation, opinion or understanding over another perspective that is potentially equally valid
Types: age, disability, ethnicity, gender, marital status, weight, origin, political beliefs, race, religion, social standing
Strategies to avoid misdiagnosis:
Build trusting rapport and don’t make assumptions in initial interview
Ask questions to confirm and disconfirm hypotheses
Be open to contradictory info and generate reasons by hypothesis can be wrong
Question yourself and your biases
Contributors to weight stigma
Body weight is an individual responsibility
Misinformation related to pathophysiology of weight regulation
Untrained professionals
Media/weight loss industry, public health messaging and use of BMI
Denial of preventative care based on body size/weight
Weight bias impact on care cycle
Obesity → health consequences → ↑ medical visits → biased health care → negative feelings → avoidance of health care → unhealthy behaviors and poor self-care → worsening obesity
