July 2016 Issue

CPE Monthly: Motivational Interviewing — Learn About MI's Place in Nutrition Counseling and Essential Tools for Enhancing Client Motivation
By Dawn Clifford, PhD, RD
Today's Dietitian
Vol. 18 No. 7 P. 48

Suggested CDR Learning Codes: 1000, 6010, 6020, 6070
Suggested CDR Performance Indicators: 9.1.3, 9.6.1, 9.6.4, 9.6.6
CPE Level: 1

Take this course and earn 2 CEUs on our Continuing Education Learning Library

"I know I need to get my blood pressure down. I don't want to end up on dialysis like my dad. But I just love my fast food."

"I don't mind the taste of fruits and vegetables; it's just hard to remember to buy them and then eat them before they go bad."

"I used to enjoy walking, but somehow I just got out of the habit when the weather changed."

It's no surprise to dietitians that people have mixed feelings about changing their eating and activity patterns. How can RDs help clients who are on the fence about change? They can list the many reasons that making the change will improve a client's health, but that's not likely to produce results or lifelong commitments.

Motivational interviewing (MI) is an ideal counseling style for assisting the most ambivalent clients.1 Instead of putting pressure on the client, MI supports client autonomy while at the same time inviting clients to reflect on their personal motivations for change. By putting the clients in the drivers' seat, the RD makes them feel respected, in charge, empowered, and free to make choices that best align with their goals, values, and lifestyles.

If they don't use MI, RDs may inadvertently squelch clients' desire to change.1,2 From tantrum-throwing toddlers to rebellious teenagers, humans generally don't like to be told what to do. Consider, for example, what might happen if the RD responded in an authoritarian style to the client's remarks. 

Client: I know I need to get my blood pressure down. I don't want to end up on dialysis like my dad. But I just love my fast food.
RD: You really need to take a close look at your eating habits or you may have serious health consequences.

Client: I don't mind the taste of fruits and vegetables; it's just hard to remember to buy them and then eat them before they go bad.
RD: Yes, you're wasting your money if you don't eat them.

Client: I used to enjoy walking, but somehow I just got out of the habit when the weather changed.
RD: Well then, it should be easy to pick it back up again.

In each of these responses, the practitioner risks losing a connection with the client or, even worse, the client may begin defending the choice not to change. The client's expressed resistance to change is often a result of the counselor's communication style.3 If your aim is to enhance your client's motivation to change, a gentler approach is needed to make the client feel respected, supported, and free to make health decisions.

This continuing education course provides an overview of MI in nutrition counseling, offering readers essential tools for enhancing client motivation. MI strategies are intermixed with sample dialogue to demonstrate application of techniques. Skill-building exercises are designed to help nutrition professionals develop proficiency in MI.

This course offers a starting point in MI training by providing an overview of the techniques as well as examples of how to apply these concepts in the dietetics setting. Training doesn't stop here. In addition to didactic instructions, training programs typically include counseling videos, live demonstrations, group activities, partnered activities, and ongoing coaching/supervision. MI trainers and practitioners often report that gaining proficiency and competency in MI is a journey, not a destination.

The History of MI
According to motivationalinterviewing.org, MI is "a person-centered counseling style for addressing the common problem of ambivalence about change." The founding fathers of MI, William R. Miller, PhD, and Stephen Rollnick, PhD, were addiction counselors in the 1980s who noticed that client openness vs defensiveness was a product of the therapeutic relationship. They began inviting their clients to voice personal reasons for change instead of telling their clients why they should change. They found this simple adjustment to their communication style resulted in improved client outcomes and wrote a book to describe these techniques in 1991.4 Since the '90s, the technique has evolved and spread rapidly to other areas of health care, corrections, and education.5-7 Nearly 300 studies have been conducted on the use of MI in health behavior change since its inception in the 1980s.8

In the last few decades, substantial support has emerged for the use of MI in nutrition counseling.9-11 In 2004, VanWormer and Boucher conducted a review of the literature to determine the efficacy of MI for diet modification. From the five studies that had been conducted at the time, they noted that participants receiving MI reduced energy from fat and sodium intake, and increased fruit and vegetable consumption.9

Since then, MI has become a primary counseling technique employed by dietitians everywhere. Researchers continue to assess the use of MI when working with clients in different life stages and from different ethnic groups with cardiovascular disease, diabetes, and weight concerns.12-17

Armstrong and colleagues confirmed the effectiveness of MI for counseling individuals with weight concerns when they conducted a meta-analysis of 11 randomly controlled trials in which MI was compared with a control group.14 In another review on MI in improving cardiovascular health, five studies were included in the systematic review with mixed results.15 While clients in the MI group made significant changes as a result of the counseling, changes did not differ significantly from the control groups for most of the studies. Researchers have also tested the use of MI in diabetes care.16,17 A multicenter randomized controlled trial of MI in teenagers with diabetes had promising results with mean A1c levels significantly lower in the MI group compared with the control group.16

One key element in improving client outcomes is providing thorough MI training to practitioners, students, and interns. A systematic review of MI training published in 2009 included 27 studies of programs of various lengths that educated doctors, nurses, medical students, social workers, substance abuse and mental health practitioners, and dietitians.18 Trainings ranged from 20 minutes to several hours, days, or weeks. Overall, training results were favorable, with most programs increasing the participants' knowledge of MI, confidence in using MI, interest in learning more about MI, intention to use MI, and general MI skills. Many dietitians feel inadequately trained in MI,19 and beginning training at the didactic level can enhance MI knowledge and skills.20

The total number of training hours needed to achieve MI proficiency in nutrition counseling is unknown. A two-day training resulted in improved skills and patient outcomes for two dietitians in New Zealand.21 In another study with 37 practicing dietitians, the one-half who received a three-day MI training displayed more empathy and change-focused statements than did dietitians who did not receive training.10

In the last 30-plus years, MI research and practice have grown exponentially. What started out as an alternative counseling technique has grown into a mainstream communication style that has touched every area of patient care.

An Overview of MI
An MI counselor is compassionate and nonjudgmental, qualities displayed through the use of specific counseling techniques; this is known as the "spirit of MI."1 Responses to clients are typically in the form of reflective listening, or paraphrasing, open-ended questions, and affirmations. At times, MI counselors may provide clients with information or behavior change strategies, but these insights are provided only with the clients' consent and generally after exploring the clients' readiness to change and their knowledge gaps.

An MI session commonly includes the following four segments, known as "processes": engage, focus, evoke, and plan. The session begins with the RD engaging the client in a conversation. From there, the practitioner invites the client to focus on a specific behavior change topic, asks specific questions to evoke motivation, and then, if the client is ready, a plan can be formulated, which typically includes some type of behavior change goal. Sessions don't always move sequentially, nor do they need to. However, knowledge of these processes can provide framing, structure, and direction to support the client in discussing behavior change.

MI was developed in response to widespread ambivalence to change. Client motivation and readiness to change varies greatly in every setting of dietetics. Even if clients schedule appointments without coercion from a physician, they may still be hesitant to make a change. Clients often fantasize about positive outcomes associated with behavior change such as lower cholesterol, blood pressure, and blood sugar or improved energy but find making the changes necessary to achieve these outcomes to be overwhelming. An RD skilled in MI can assist clients in breaking the behavior change process into smaller, more manageable pieces.

Throughout MI sessions, counselors direct clients to examine and resolve ambivalence, while inviting them to decide how they will move forward.

The Spirit of MI
The "spirit of MI" is a phrase used to describe the counselor's disposition. In general, the spirit of MI refers to the practitioner's attempt to create a collaborative partnership while expressing empathy, compassion, and respect for clients and their situations.1 The counselor invites clients to share personal interests and motivations for making behavior changes and elicits their ideas for how they might go about making the change. As Miller and Rollnick discovered early in their work, when clients voice personal internal motivations, they are more likely to move toward change than when they are given lists of reasons they should change.

The spirit of MI encompasses the following four key counseling characteristics: partnership, acceptance, compassion, and evocation.

Partnership
In MI, the RD seeks to determine what might work best for the client. Instead of telling clients what to do or not do, the practitioner asks clients what changes they are interested in making and what ideas they have for how they might go about making those changes. If their clients get stuck, RDs are prepared to provide ideas, but they maintain and communicate the belief that their role is to provide support and that clients know the behavior change strategies that will work best for them.

Acceptance
By demonstrating complete acceptance of the client and where the client is in the behavior change process, the RD sets aside judgments or preconceived notions. The RD uses verbal and nonverbal cues to express empathy and to support the client by affirming positive traits. The practitioner also supports client autonomy instead of attempting to exert control and make the client take action. Overall, the RD's aim is to demonstrate the worth and potential of every client encountered.

Compassion
As a member of a helping profession, an RD practicing MI makes a commitment to pursue the clients' welfare and best interests instead of focusing on self-gain. This is expressed through being authentic and expressing empathy and support.

Evocation
A key objective of MI is to elicit language from the client demonstrating a positive attitude toward changing a behavior and to emphasize such client statements through paraphrasing or reflective listening responses.

The Four Processes
The four processes (engage, focus, evoke, and plan) represent the different types of conversations an RD is likely to have during an MI session. Initial contact with the client begins the engaging process. The client-counselor relationship begins to form during initial contact, whether the RD walks into the patient's hospital room or meets the client in a clinic lobby. The engaging process encompasses the verbal and nonverbal communication used to build a connection between client and RD. The RD asks or confirms the reason for the visit and aims to fully understand the client's situation. In keeping with the nutrition care process, if the RD prefers to conduct an oral assessment to find out more about a client's eating habits, activity patterns, medications, labs, and health history, it is best to do so after the initial engaging process.

Once the RD has built rapport and has a good idea of what the client is hoping to gain from the session, the conversation often shifts to the second process, which is focusing on one specific topic or behavior change (such as adding more fruits and vegetables to the client's diet). Sometimes the client has a specific behavior change in mind before arriving at the RD's office; other times the RD may present a menu of topics or behavior change ideas and invite the client to select one that feels doable.

The evoking process involves asking questions designed to elicit the client's desire, ability, and reasons for attempting a behavior change. This is known as "change talk." Once clients express a significant amount of change talk and seem generally ready to attempt a behavior change, the client and RD can collaborate to create an implementation plan.

During the planning process, the RD typically invites the client to come up with a specific behavior change goal (such as adding a salad to dinner three nights a week) and then the RD asks the client what he or she might need to be successful in reaching the goal. For example, the client may need assistance with meal planning, recipe ideas, or tips for storing fruits and vegetables. These topics can be discussed as needed to support the client's attempt to change behavior.

While engaging clients in a conversation and building rapport is the first process in an MI session, the remaining three processes don't necessarily fall in the order presented. It's important to remain flexible and open to clients' needs. For example, at any point a client may decide he or she no longer wants to work on eating more fruits and vegetables and instead wants to talk about physical activity. In another appointment, the RD may be in the evoking process and discover that the client isn't ready for change yet, so the conversation never reaches the planning process. MI is a bit of a dance; the RD is providing some direction, while at the same time staying open to the client's wants and needs.

The following are a few strategies for each of the four processes.

Engage
When engaging clients, provide a warm, friendly greeting. Let clients know how much time you have to talk and ask open-ended questions to find out what they hope to gain from the sessions. The rapport-building process often begins with the initial handshake and continues as you attempt to understand the client's health concerns and purpose for the session. However, the engaging process never really stops. It's important to maintain that connection with the client throughout the session.

Focus
Once you establish a relationship with your client, you can invite him or her to consider a specific topic. You can simply ask a specific question (such as, "What are you interested in talking about today?") or offer a variety of behavior change ideas and see if the client is interested in choosing one to discuss further, as in the following scenario:

RD: Given your recent diagnosis of diabetes, is there a specific change you've already thought about making?
Client: No. It's all very overwhelming, and I don't even know where to start.
RD: Would you be interested in hearing some changes that other clients of mine with diabetes have made?
Client: Yes, that might be helpful.
RD: Some like to take a look at planning more meals and snacks throughout the day to keep their blood sugars consistent. Others like to brainstorm ways to add more fiber and protein to their diets, which might also help. Another idea is to discuss ways to be more physically active. Which of these topics, if any, would you like to focus on today?

Evoke
Clients may not be ready to make a change right away. Therefore, it's important to take time to find out more about their thoughts and feelings about change. During the evoking process, use open-ended questions aimed at promoting change talk. Find out why they want to make the change and have them voice the benefits that are most important to them. Invite them to imagine how their lives might improve if they were to make the proposed changes. The more change talk the client speaks during the session, the more likely the client will be to make the change.22

Plan
Once clients seem to be committed to attempting a behavior change, guide them in developing a plan for implementation that works with their lifestyle. It's important that the client leads this process. You can ask questions such as, "How do you think you'll go about making that change?" You also can provide suggestions if the client runs out of ideas. The key is to allow clients to choose behavior change strategies and set their own behavior change goals. When the goal-setting process is client-led, clients will feel empowered to follow through.

The OARS
RDs guide clients through the four processes using a strategic mix of open-ended questions, affirmations, reflections, and summaries (OARS), also known as the "microskills of MI."

Open-Ended Questions
To encourage the client to share all information that may be helpful, open-ended questions are preferred over closed-ended questions. The practitioner uses these questions to find out more about their clients' experiences while at the same time interspersing strategic evoking questions throughout the sessions so clients can express why making the changes might be beneficial. A closed-ended question, such as "Do you want to make this change?," would elicit only a yes-or-no response, but an open-ended question, such as "How would making this change make your life better?," invites the client to respond with specific reasons for how making the change would be beneficial.

Affirmations
In MI, it's important to listen for expressions of clients' character strengths and mention these throughout the session. An example of an affirmation a practitioner might provide is, "You're very committed to raising a healthy family," or "You have a lot of perseverance." Affirmations, made intermittently throughout sessions, support the client-practitioner relationship and enhance client confidence in behavior change.

Reflections
Reflections are paraphrases of what the client is saying that often go beyond mirroring their words to reflect underlying meaning. For example, if a client says, "I felt so bad this morning. I wished I hadn't eaten out last night," the RD might say, "You've found that when you eat lighter meals, you experience less guilt and feel better in the morning." In this reflection, the RD takes a guess at some of the feelings the client is experiencing. A general rule of thumb is to aim to provide two reflections for every question you ask the client.1 Therefore, in MI, reflective listening statements follow most client responses, making reflections the most frequently used microskill. Some reflections are very short and are similar to what the client says, while others might be lengthier or more complex, taking a guess at underlying meanings behind the client's spoken words.

Summaries
Summaries are extended reflections offered now and then throughout the session to piece together different statements the client has made. A practitioner might say, for example, "Overall, you sound very committed. You came to this session because your doctor insisted you meet with a dietitian. Now that you've shared the many ways your life and health might improve if you were to make some changes to the foods you eat, it sounds as if you're interested in exploring some new cooking techniques at home. You mentioned that because you're a busy working mother, you could only successfully make a change if it doesn't take any more of your time." In a few sentences, the RD summarized some key pieces of the session so far. Doing so demonstrates active listening while allowing for transitions to new topics, as needed.

Evoking and Reflecting Change Talk
Clients do most of the talking during MI sessions. The word "interviewing" in the context of MI indicates the importance of asking open-ended questions and eliciting clients' thoughts and feelings about change throughout the sessions. Clients say many things during a session, everything from why they came to the appointment to how they feel about their mother's cooking, but their most important statements are those that express an interest in making behavior changes (change talk). When counselors remain adherent to MI techniques, client change talk increases, as does the likelihood of client behavior change.22,23 Therefore, evoking and reflecting change talk is the heart of MI.

The following are examples of change talk:

• "My mother has diabetes and it's hard for me to even watch her check her blood sugars in the morning without getting squeamish. I really don't want to follow in her footsteps."
• "About 1 o'clock every day I feel like I have to take a nap. I'm tired of feeling this way and don't want to rely on energy drinks to get me through."
• "I've been letting my son watch way too much TV lately. I need to get him outside and playing more with friends in the neighborhood."

At times, clients also express disinterest in making behavior changes, which is called "sustain talk."

The following are examples of sustain talk:

• "I tried to stop using the salt shaker, but it was just too hard. My food tasted awful, so that didn't last very long."
• "I've been really busy lately, so it's hard to imagine having any time for cooking."
• "I know I don't have the perfect diet, but it's better than most people I know. It's good enough."

Most clients are ambivalent about change. On one hand, they have a true desire to make changes that support health and well-being, and on the other hand, there are very good reasons why they haven't yet made the necessary changes. These might be matters of habit, convenience, taste preferences, or emotional needs. Before guiding clients to devise helpful strategies (whether those are making fruit smoothies, switching from hamburgers to veggie burgers, eating more fish, or walking the dog), it's important to evoke change talk. Hold your nutrition and fitness tips for the end of sessions after clients have expressed interest in attempting a change and personal reasons for doing so. The more change talk clients express during sessions, the more likely they will follow through with making changes.22

The spirit of MI, the four processes, and the OARS work in concert to draw out and emphasize clients' desires, needs, and abilities, as well as their motivations for positive behavior change. As a practitioner, the questions you ask, the reflections you provide, and the processes you use are dictated by your clients' expressions of change talk. MI practitioners become attuned to change talk and take every opportunity to reflect it back so that their clients hear it, too. If change talk is intermittent or sporadic, clients may not be ready to make a change plan. However, if clients list many reasons why a change might do them good and have ideas about how they can make the change work, it may be time to invite them to set specific goals to test the waters of new behaviors.

In MI, practitioners attempt to evoke change talk from clients by asking strategic open-ended questions such as the following:

• "What do you dislike about the way things are now?"
• "What concerns you most about your recent diagnosis?"
• "In what ways would making this change make your life better?"
• "How interested are you in making this change on a scale from zero to 10, with zero being 'not at all interested,' and 10 being 'very interested?' Tell me more about why you didn't choose a lower number."

In response to such questions, clients will likely respond with change talk. The key is for practitioners to listen for change talk, and in response provide reflections and summaries that emphasize change talk.

Consider the three client statements described previously. Each of the following includes some change talk and some sustain talk, as indicated below:

• "I know I need to get my blood pressure down. I don't want to end up on dialysis like my dad [change talk]. But I just love my fast food [sustain talk]."
• "I don't mind the taste of fruits and vegetables [change talk], it's just hard to remember to buy them and then eat them before they go bad [sustain talk]."
• "I used to enjoy walking [change talk], but somehow I just got out of the habit when the weather changed [sustain talk]."

To highlight the change talk, provide responses that emphasize it. Do this by either reflecting just the change talk or by mentioning both the sustain and change talk, if both are expressed. If you choose the latter, reflect first on the sustain talk, then on the change talk. When you end your sentences with the change talk, clients are more likely to express further change talk than they would if you ended with the sustain talk.1

The following are several possible practitioner responses to the clients' statements above, each of which emphasize the change talk:

"I know I need to get my blood pressure down. I don't want to end up on dialysis like my dad [change talk]. But I just love my fast food [sustain talk].
• "You saw the hard road your dad was on and you don't want to follow in his footsteps [reflects change talk only]."
• "You like the taste of fast food but you don't like what it does to your body [reflects sustain talk followed by change talk]."
• "You'd like to find foods that taste good and also lower your blood pressure [reframes sustain talk into change talk]."

"I don't mind the taste of fruits and vegetables [change talk], it's just hard to remember to buy them and then eat them before they go bad [sustain talk]."
• "You enjoy fruits and vegetables [reflects change talk only]."
• "You see fruits and vegetables as an important step to improving your health [reflects change talk only]."
• "You'd like to figure out a way to conveniently weave more fruits and vegetables into your meals and snacks [reframes sustain talk into change talk]."

"I used to enjoy walking [change talk], but somehow I just got out of the habit when the weather changed [sustain talk]."
• "When the weather is comfortable, you enjoy walking [reflects sustain talk followed by change talk]."
• "You'd like to find an activity you enjoy on days when the weather is lousy [reframes sustain talk into change talk]."
• "Walking is something that's fun and makes you feel good [reflects change talk only]."

Clearly, there's more than one way to reflect and emphasize change talk.

At times, rather than using the clients' words, it may be helpful to anticipate change talk that is implied but not expressed directly. These types of reflections help move the client forward, enhance motivation, and often elicit more change talk.

Another type of client language that may emerge is discord—expressions of anger or hostility toward the practitioner. Clients may be angry or agitated before even meeting their practitioner or may react to something said by their practitioner. The best way to respond is to use reflective listening and emphasize client autonomy, as in this example:

Client: Are you just going to tell me to stop eating rice, like my last dietitian?
Practitioner: You didn't like being told what to do and this time you'd really like to have a say in the changes that work best for you.
Rationale: With this response, the practitioner affirms the client's autonomy while validating the discomfort that arose from the previous counseling experience.

Consider these three examples of reflective listening that emphasize change talk while staying true to the spirit of MI.

Example 1
Client: Whatever you do, don't take away my soda. It's the last vice I have left!
Practitioner: You've already made a lot of positive changes that support your health and from here on out you'd like to have a say in the changes you make.
Rationale: This response affirms the client regarding previous positive behavior changes while also expressing client autonomy in moving forward.

Example 2
Client: The salted crackers taste a lot better than the unsalted crackers, but I don't like the way I swell up when I eat them.
Practitioner: You notice certain foods make you feel better than others.
Rationale: This response emphasizes the change talk without repeating exactly what the client is saying.

Example 3
Client: I've got to do something. I don't like the way I look. I don't feel good about myself.
Practitioner: You want to find positive self-care strategies that make you feel better in your skin.
Rationale: The practitioner reflects what the client is saying while also directing him or her toward developing a healthy body image and sustainable changes instead of extreme weight loss measures.

Strategies for Getting Started
Becoming proficient in MI requires extensive training and practice. While the concept of following the client's lead may sound fairly simple, it may not be as easy as it sounds. The following are a few steps to start making your nutrition counseling sessions more MI adherent.

Step 1: Reflect Consistently
One way to begin enhancing your MI skills is to be more consistent with reflective listening. This may be challenging at first. Begin by providing some type of reflection almost every time the client speaks. It's not necessary to reflect complete client statements each time the client speaks. Sometimes short pieces of what the client says or implies are all you need to demonstrate you're listening and trying to understand. As you get more comfortable incorporating reflective listening, try specifically reflecting the change talk you hear.

Step 2: Evoke Change Talk
Once you become more comfortable with reflective listening, the next step might be to try asking more questions that evoke change talk. Try setting a small goal for yourself, such as asking the client three questions that evoke change talk before inviting the client to discuss specific behavior change strategies.

Step 3: Ask Permission
One way to express partnership and autonomy is to ask for clients' permission before providing suggestions. By simply adding this important question to your conversations about change—"Would you be interested in hearing some ideas?"—you can shift the dynamic of the relationship into a partnership and make clients feel respected.

Step 4: Start With the Client
Before providing suggestions for snacks, meals, and physical activity, determine your clients' ideas. If they don't have any ideas, ask permission to provide some. Instead of saying, "Try this three days a week," invite clients to set their own goals by asking, "How many days a week would it be feasible to try this new change?" Clients may also bring up barriers to making changes. Instead of offering suggestions to overcome these barriers, ask clients if they have ideas.

Step 5: Assess Client Confidence
Before the end of your sessions, it's useful to use a confidence ruler (also known as a scaling question) to find out how clients feel about the change. Try ending sessions with a question such as, "How confident are you that you can walk your dog three days a week on a scale from zero to 10, with zero being 'not at all confident,' and 10 being 'very confident?'" Once clients mention a number, invite them to share why they selected that number and troubleshoot any potential barriers to change.

Conclusion
Whether you have long outpatient counseling sessions or brief inpatient interactions, MI skills can be incorporated into any conversation. Some interactions are so brief that you may not have time to cover the four processes of MI. However, simply using reflective listening and letting clients come up with their own goals can go a long way toward enhancing outcomes.

— Dawn Clifford, PhD, RD, is an associate professor at California State University, Chico, in the areas of nutrition counseling and education, and author of Motivational Interviewing in Nutrition and Fitness.

 

[Sidebar]

Additional Resources
• Motivational Interviewing: www.motivationalinterviewing.org
• Steps to Counseling Excellence: A Program for Practicing Nutrition Professionals: http://www.mollykellogg.com/products/steps-to-counseling-excellence/
• Clifford D, Curtis L. Motivational Interviewing in Nutrition and Fitness. 1st ed. New York, NY: Guildford Press; 2016.
• Miller WR, Rollnick S. Motivational Interviewing: Helping People Change. 3rd ed. New York, NY: Guilford Press; 2012.
• Wagner CC, Ingersol KS. Motivational Interviewing in Groups. 1st ed. New York, NY: Guilford Press; 2012.
• Rollnick S, Miller WR, Butler CC. Motivational Interviewing in Health Care: Helping Patients Change Behavior. 1st ed. New York, NY: Guilford Press; 2007.
• Kellogg M. Counseling Tips for Nutrition Therapists: Practice Workbook Series (Vol 1-3). Philadelphia, PA: Kg Press; 2006, 2009, 2014.
• Glovsky ER, ed. Wellness, Not Weight: Health At Every Size and Motivational Interviewing. San Diego, CA: Cognella Academic Publishing; 2013.


Learning Objectives
After completing this continuing education article, nutrition professionals should be better able to:
1. Define motivational interviewing (MI).
2. Interpret the evidence that supports the effectiveness of MI in nutrition counseling.
3. Describe the spirit of MI.
4. Demonstrate the four processes of MI.
5. Use open-ended questions, affirmations, reflections, and summaries that emphasize and evoke client motivation for change.
6. Apply three strategies for making counseling interactions more client led.
7. Distinguish between MI and non-MI adherent dialogue.


CPE Monthly Examination

1. Which of the following is one of the four processes of a motivational interviewing (MI) session?
a. Elicit
b. Partner
c. Evoke
d. Assess

2. Which of the following is most strongly associated with client behavior change?
a. Change talk from the client
b. Compliments from the client
c. Reflective listening from the RD
d. Open-ended questions from the RD

3. "When my boyfriend broke up with me last week, I sat around and ate a bunch of ice cream. It honestly seemed to help." This client statement is an example of which of the following?
a. Change talk
b. Sustain talk
c. Discord
d. Empathy

4. "My doctor told me I have high cholesterol. It sort of freaked me out because my uncle just had triple bypass surgery last spring." This client statement is an example of which of the following?
a. Change talk
b. Sustain talk
c. Discord
d. Apathy

5. "You've endured a lot of hardship, and as a result, you're stronger and more determined." This practitioner response is an example of which of the following?
a. An open-ended question
b. An affirmation
c. A reflection
d. A summary

6. Which of the following is true regarding MI research?
a. Very little research has been conducted to assess the efficacy of MI.
b. MI has been tested only in addiction counseling.
c. Most researchers have found improved patient outcomes as a result of MI interventions.
d. MI training research is very limited and has been assessed only on medical students.

7. Which of the following would be the most MI-adherent way to respond to this client statement? "I've been drinking too much coffee lately. And not just black coffee; I order those yummy ones with sweeteners and flavorings. It's an expensive habit and while it's keeping me awake in class, it can't be good for my health."
a. "Yes, you really shouldn't have too many of those."
b. "Why not just order the black coffee and throw in your own milk and low-calorie sweeteners?"
c. "You'd like to find healthier and cheaper ways to stay alert in the morning."
d. "Yes, those drinks are really popular right now."

8. Which of the following counseling characteristics is considered part of the spirit of MI?
a. Acceptance
b. Alignment
c. Assessment
d. Agreement

9. Which of the following is an open-ended question that is useful in evoking change talk?
a. "How are you today?"
b. "What would you like to talk about today?"
c. "How often do you do that?"
d. "How would making this change make your life better?"

10. What's the best way to respond to change talk?
a. Ignore it.
b. Reflect the change talk you hear.
c. Cheer your client on.
d. Talk about ways you've been successful making changes.


References
1. Miller WR, Rollnick S. Motivational Interviewing: Helping People Change. 3rd ed. New York, NY: Guilford Press; 2012.

2. Moyers TB, Martin T. Therapist influence on client language during motivational interviewing sessions. J Subst Abuse Treat. 2006;30(3):245-251.

3. Miller WR, Benefield RG, Tonigan JS. Enhancing motivation for change in problem drinking: a controlled comparison of two therapist styles. J Consult Clin Psychol. 1993;61(3):455-461.

4. Miller WR, Rollnick S. Motivational Interviewing: Preparing People to Change Addictive Behavior. New York, NY: Guilford Press; 1992.

5. Knight KM, McGowan L, Dickens C, Bundy C. A systematic review of motivational interviewing in physical health care settings. Br J Health Psychol. 2006;11(Pt 2):319-332.

6. McMurran M. Motivational interviewing with offenders: a systematic review. Leg Criminolog Psychol. 2009;14(1):83-100.

7. Frey AJ, Cloud RN, Lee J, et al. The promise of motivational interviewing in school mental health. School Ment Health. 2011;3(1):1-12.

8. Copeland L, McNamara R, Kelson M, Simpson S. Mechanisms of change within motivational interviewing in relation to health behaviors outcomes: a systematic review. Patient Educ Couns. 2015;98(4):401-411.

9. VanWormer JJ, Boucher JL. Motivational interviewing and diet modification: a review of the evidence. Diabetes Educ. 2004;30(3):404-419.

10. Brug J, Spikmans F, Aartsen C, Breedveld B, Bes R, Fereira I. Training dietitians in basic motivational interviewing skills results in changes in their counseling style and in lower saturated fat intakes in their patients. J Nutr Educ Behav. 2007;39(1):8-12.

11. Macdonell K, Brogan K, Naar-King S, Ellis D, Marshall S. A pilot study of motivational interviewing targeting weight-related behaviors in overweight or obese African American adolescents. J Adolesc Health. 2012;50(2):201-203.

12. Bean MK, Powell P, Quinoy A, Ingersoll K, Wickham EP, Mazzeo SE. Motivational interviewing targeting diet and physical activity improves adherence to paediatric obesity treatment: results from the MI values randomized controlled trial. Pediatr Obes. 2014;10(2):118-125.

13. Miller ST, Oates VJ, Brooks MA, Shintani A, Gebretsadik T, Jenkins DM. Preliminary efficacy of group medical nutrition therapy and motivational interviewing among obese African American women with type 2 diabetes: a pilot study. J Obes. 2014;2014:345941.

14. Armstrong MJ, Mottershead TA, Ronksley PE, Sigal RJ, Campbell TS, Hemmelgarn BR. Motivational interviewing to improve weight loss in overweight and/or obese patients: a systematic review and meta-analysis of randomized controlled trials. Obes Rev. 2011;12(9):709-723.

15. Thompson DR, Chair SY, Chan SW, Astin F, Davidson PM, Ski CF. Motivational interviewing: a useful approach to improving cardiovascular health? J Clin Nurs. 2011;20(9-10):1236-1244.

16. Channon SJ, Huws-Thomas MV, Rollnick S, et al. A multicenter randomized controlled trial of motivational interviewing in teenagers with diabetes. Diabetes Care. 2007;30(6):1390-1395.

17. Wang D, Li XY, Zhang LN, Zhou L, Zhang KJ. Effects of motivational interviewing on lifestyle modification and diabetes prevention in adults with pre-diabetes [published online February 23, 2015]. Diabetes Res Clin Pract. doi: 10.1016/j.diabres.2015.01.042.

18. Madson MB, Loignon AC, Lane C. Training in motivational interviewing: a systematic review. J Subst Abuse Treat. 2009;36(1):101-109.

19. Rapoport L, Perry KN. Do dietitians feel that they have had adequate training in behaviour change methods? J Hum Nutr Diet. 2000;13(4):287-298.

20. Smart H, Clifford D, Morris MN. Nutrition students gain skills from motivational interviewing curriculum. J Acad Nutr Diet. 2014;114(11):1712-1717.

21. Britt E, Blampied NM. Training dietitians in motivational interviewing: a pilot study of the effects on dietitians and patient behavior. Motivational Interviewing Training Res Implementat Pract. 2014;1(3):7-12.

22. Moyers TB, Martin T, Christopher PJ, Houck JM, Tonigan JS, Amrhein PC. Client language as a mediator of motivational interviewing efficacy: where is the evidence? Alcohol Clin Exp Res. 2007;31(10 Suppl):40s-47s.

23. Gaume J, Bertholet N, Faouzi M, Gmel G, Daeppen JB. Counselor motivational interviewing skills and young adult change talk articulation during brief motivational interventions. J Subst Abuse Treat. 2010;39(3):272-281.
ADVERTORIAL