Guide to Motivational Interviewing

One of the primary roles of a dietitian working in outpatient nutritional counseling is to help patients work toward sustainable behavior change. It is common for patients to have mixed feelings about changing their health behaviors, and sometimes simply educating patients on why making XYZ change may benefit them is not enough to elicit motivation. That is where motivational interviewing comes in.

• MI is a guiding style of communication, that sits between following (good listening) and directing (giving information and advice).

• MI is designed to empower people to change by drawing out their own meaning, importance and capacity for change.

• MI is based on a respectful and curious way of being with people that facilitates the natural process of change and honors client autonomy.

The primary goal of MI is to identify ambivalence and work to resolve it; however, the other goals of MI are to engage clients, encourage change talk, and evoke motivation to make positive changes

There are four main processes that make up Motivational Interviewing:

• Engaging

  • Engaging involves building a positive relational foundation with a patient. The rapport-building process often begins with the initial introduction and continues as you attempt to understand the patient's health concerns and purpose for the session, but this process never stops.

• Focusing

  • Focusing is the process of helping the patient identify a target area to focus on during a session. Once you establish a relationship with a patient, you can help them consider a specific topic by directly asking the patient what they are interested in discussing or if they are not sure, offer some topics to start with.

• Evoking

  • Patients are not always ready to make changes right away. Therefore, it's important to take time to find out more about their thoughts and feelings about change and promote change talk instead of sustain talk. We can help them to imagine how their life may improve if they made changes to their health behaviors and increase their likelihood of making those changes.

  • Change Talk:

    • “I really need to do this. I know making these changes will help me feel better.”

    • Sustain Talk:

    • “I didn’t make any of the changes you suggested. I just don’t have any motivation right now.”

• Planning:

  • Once patients seem to be committed to attempting a behavior change, RDs can help them develop a unique and individualized plan for implementation that works with their lifestyle. This process should be patient led and involve asking key questions to determine readiness for that plan.

  • Examples of questions to ask when making a plan:

    • At this point, what are you thinking about doing or not doing?

    • What’s the next step, if any?

    • What happens next?

    • Where does this leave you now?

    • What changes, if any, are you thinking about making?

    • Based on our conversation, what are you going to do?

    • How would you like things to turn out?

  • It's important that planning is collaborative and patient led. Collaboration is important for building rapport and facilitating trust with a patient. This does not mean that the practitioner automatically agrees with the patient about the nature of the problem or the changes that may be most appropriate.

    • You can ask questions such as, "How do you think you'll go about making that change?" and provide suggestions if the patient 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 patient-led, patient’s will feel empowered to follow through.

Motivational Interviewing is guided by four key principles:

• Express Empathy

  • Empathy is a key component of motivational interviewing. The RD listens carefully to the patient and conveys that they understand the patient’s feelings, beliefs, and experiences.

  • Examples of Expressing Empathy:

    • Pt: “It’s takes so much effort to do this.”

    • RD: “Yes, making these changes is very hard work.”

    • Pt: “I followed your recommendations perfectly and my blood sugar was still high, it was so irritating.”

    • RD: “It sounds like that was a really frustrating experience.”

    • Pt: “My Mom told me I had to add fruit with my lunch, but I already had juice packed. I don’t need any more. ”

    • RD: “That makes sense, I can totally see why you were upset.”

• Support Self Efficacy

  • Motivational interviewing posits that patient’s possess the strength and ability to grow and change—even if past attempts at change have failed. The RD supports the patient’s belief in themselves that they can change. The RD may do this by calling attention to the patient’s skills, strengths, or past successes.

  • Examples of Statements that Support Self-Efficacy:

    • “It seems like you have put a lot of thought into these goals.”

    • “I can tell how much you care about trying these new strategies.”

    • “It sounds like you’ve taken some great steps this week, how do you feel about them?”

• Roll with Resistance

  • If the patient is struggling to change, they may resist potential solutions or the RD’s guidance. In motivational interviewing, the RD avoids becoming defensive or argumentative if they encounter resistance. Instead, they help the patient identify the problem and solution themself. The RD doesn’t impose their viewpoint on the patient but helps the patient consider multiple viewpoints.

    • Example of rolling with resistance:

      • Pt: “I don’t have an issue with desserts, I just don’t like sweet foods. I wish people would just lay off.”

      • RD: “Others may worry there is something going on, but there isn’t.” (Reflect rather than argue)

      • Pt: “Exactly, they’re wrong.”

      • RD: “What would it look like if someone did have an issue with desserts?” (Have patient consider different view point)

• Develop Discrepancy

  • The RD helps the patient identify discrepancies between their present circumstances and their future goals. What thoughts and behaviors do they need to change to achieve those goals? The RD guides the patient in spotting this discrepancy and solutions to reduce it.

    • Example of helping a patient identify discrepancy:

      • Pt: “I notice alcohol makes my IBS symptoms a lot worse the next day, but It’s the only thing that helps me relax at the end of the day so I can’t change that right now .”

      • RD: “You find drinking helps reduce your stress in the evening, and you are also concerned about the digestive discomfort it gives you the following day.”