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09/23/18

The Stronger U Journal Club: All About Motivational Interviewing

This month, for the Stronger U Journal Club we talked about a topic that’s near and dear to my heart: Motivational Interviewing.

Motivational Interviewing can often be seen as a deep and complex topic that drifts too far into the coach-playing-therapist side of things for those who are untrained or unfamiliar with MI and it’s various uses. But in reality, it’s a widely regarded and accepted practice. Something that has been around since the 1980’s and is only becoming more and more prevalent as more coaches, practitioners, counselors, dietitians, and others are exposed to the concepts of MI.

Talking about Motivational Interviewing as the centerpiece of our Journal Club is a bit of a departure from what most of our Journal Club’s will typically be about. The reason being that unlike last month where we talked about a topic that’s a bit easier to control in a research setting, like diet breaks. Setting up a well-controlled research experiment to view what happens when you start asking people questions isn’t exactly the easiest thing there is.

On top of that, this isn’t a topic that is easily studied in a research setting – so in order for us to do the best we could, Dr. Jessica Bachman, Coach Robbie Farlow, and myself all read the book Motivational Interviewing in Nutrition and Fitness – as well as opened up the call for all the coaches to join us in reading that book to have a more complete and concrete understanding of what MI is and how it’s practiced.

What is Motivational Interviewing?

Motivational Interviewing can be defined as:

Motivational interviewing is a counseling method that helps people resolve ambivalent feelings and insecurities to find the internal motivation they need to change their behavior. It is a practical, empathetic, and short-term process that takes into consideration how difficult it is to make life changes.”

In practice, Motivational Interviewing is nothing more than the practice of asking open-ended questions so that you can continue to create a higher resolution picture of what your client is doing, what is happening in their life, and how to best guide them.

Motivational Interviewing is a widely supported method that’s practiced in a number of different settings, ranging from being used by personal trainers in a gym setting, dietitians in a clinical setting, to therapists putting these principles in practice in a counseling setting.

It’s a skill set that is practiced by a number of different professionals in a number of different areas. At the very core of it, there are two qualities that someone has to use when practicing motivational interviewing:

  • Care for the client and their autonomy
  • Ask open-ended questions and then listen

When practiced well, each question builds off of the previous one, slowly walking the client towards an action plan that they have built for themselves. One that they believe is entirely manageable for them and where they are at right now.

Motivational Interviewing, what you need to know.

Motivational Interviewing operates under the hallmark belief that what holds most people back from seeing meaningful change in their life is ambivalence. Or, put another way, a mismatch somewhere deep down between someone’s values and their actions.

Motivational Interviewing uses some of the same underpinnings as Self-Determination Theory when talking about human behavior change: namely stating that in order for people to follow through on long-lasting change, they need to feel autonomous in what it is that they’re doing.

In other words: for people to effectively change, they need to feel like they’re making the decision to change, controlling the pace at which things change, and are the ones who are unequivocally in the driver’s seat of their quest for change.

Where Motivational Interviewing comes into play is whenever a practitioner notices a discrepancy between someone’s values and actions. Then that practitioner can use Motivational Interviewing, a series of open-ended questions, to help that person see the discrepancy and figure out what might be the most effective course of action, for them, to handle that.

Change talk vs. Sustain talk.

One of the ways in which someone who practices MI looks to identify things they might want to focus on is that they start looking for what is called change talk and sustain talk. We do this because we know that change talk is something that bleeds over into behavior change – literally trying to speak that change into existence.

Whereas someone who is deeply rooted in practicing sustain talk might not actually be ready to take on a major change yet.

Learning to identify the difference between the two not only helps to tell you where someone is at in their readiness for change, but it also helps to provide a framework to build off of so that you can work with that person to put together a plan that works for them.

Change talk looks like:

  • “I’m tired of feeling sluggish. I can’t believe how out of breath I get when I walk up a set of stairs”

Whereas sustain talk looks like:

  • “I know I’d save money if I cooked more meals at home, but I hate doing dishes and cleaning the kitchen. When all is said and done, it’s easier just to get takeout”

4 Key Concepts of Motivational Interviewing.

There are 4 key concepts to Motivational Interviewing. An easy way to think about it is this:

MI, in practice, is really nothing more than asking open-ended questions. But if these 4 key values don’t exist as the reasoning behind those questions, then you’re really just asking empty questions with no regard for what the answers might be.

In order to care, ask appropriate questions, listen to the response, and then build appropriate questions off of that, there needs to be:

  • Partnership
      • The client and the Coach are partners who are collaborating together with the express goal of finding something that works, for the client.
  • Acceptance
      • Each and every single person is an individual who has their own autonomy, hopes, dreams, wishes, fears, and concerns. Each and every single person is just that, a person. It’s the practitioner’s job to accept them for exactly who they are at this moment and do everything through the lens of helping that person.
  • Compassion
      • “Be kind, for everyone you meet is fighting a harder battle.” – Plato
  • Evocation
    • This is eliciting someone’s motivation for change into change talk so that they can start putting together a plan that is manageable for them. An example might be: “How would making this change make your life better?”

Look at these as the underpinning beliefs that someone should have if they’re going to be effectively practicing Motivational Interviewing. Put simply, treat people like real and normal people, and they’re more likely to be able to change.

4 Key Processes of Motivational Interviewing.

  • Engaging
      • Warm, friendly greeting; ask rapport-building questions
  • Focusing
      • Invite the client to select a topic; present topic ideas if unsure; find out the reason behind the selection.
  • Evoking
      • Identify and respond to ambivalence; evoke change talk; assess readiness to change; transition into the planning process
  • Planning
    • Ask permission before giving information, offer information using elicit-provide-elicit; invite the client to set goals; assess barriers to change

In practice, the above is nothing more than working to make someone feel comfortable and safe, focusing on them and putting their needs first, asking questions that help them identify what is manageable for them, find ways to plan on doing those things that are manageable.

Open-ended questions vs. close-ended questions:

In my experience, the biggest actual hang-up, whenever it comes to practicing MI, is the actual involvement of open-ended questions as a way to get clients to talk, and then, in turn, give you more information to help guide them towards change.

Open-ended questions are the tools of the trade that an MI practitioner deals in, but they aren’t something that we need to make overly complicated. So in order to make things a bit easier, I wanted to put together a few different common question-starters to show which ones lead to open-ended questions and which ones lead to close-ended – yes/no style questions.

Open-ended question starters:

  • Tell me how you feel about…
  • What is it about…
  • Why do you think that…
  • How would you describe…
  • What would you like to…

Close-ended question starters:

  • Do you think…
  • Would you be willing to…
  • Are you able to…
  • Is that doable for you?

What’s important to remember is that there are typically places for both styles of questions. But in order to help someone see long-lasting change, we want to lean on more open-ended most of the time. Especially in the beginning. Where close-ended questions can be really valuable is once you’ve used open-ended questions to highlight a manageable action plan for someone, and now you’re looking to put that action plan into place.

What was the study we went over?

The actual study that we selected as the basis for our club this month was this clinical review of the use of Motivational Interviewing as a treatment practice in managing obesity and diabetes for both adult and pediatric populations.

However, the important thing to remember about this month and our journal club is that the topic we selected is one that is notoriously hard to study in a controlled research setting. When you start trying to pinpoint what happens when people ask questions of their clients and just wait for them to talk, there’s a lot to measure and try to evaluate.

This sets up a ton of headaches from the research side.

But the important thing to know is that while this topic is notoriously hard to research, which is why we made it a more practical journal club vs. talking about a specific study, is that this is a widely touted and supported practice across a number of fields.

What does the clinical review say?

Some overarching points that we all took away from looking over this clinical review:

  • MI was first introduced to health care settings working with addictions in the 1980s
  • Over time used in a wider variety of healthcare settings
      • Primarily used with chronic health conditions
      • More recently MI has been seen in use with children
  • When being used to treat obesity:
        • Results vary with the amount of treatment contact hours being a key predictor
        • Generally, we find that MI can help change underlying behaviors and assist with weight loss
  • When being used to treat diabetes:
        • Improvements in HBA1c as long as tailored to the individual
        • Feasible and effective to use with teenagers
      • Few studies that can actually evaluate the efficacy of MI
  • Generally show positive results for:
      • Retention rates and program completion
      • Improvements in eating behaviors, activity, self-image, weight, physiological markers (HDL, LDL, B/P)

Relatively few studies that have varied greatly for the following reasons:

    • Training of the practitioners
    • Number of treatment hours
    • Compliance with MI (treatment fidelity)
    • Mode of delivery (paper versus in-person consultations)
  • Well accepted practice but not a lot of research

As you can see above, MI isn’t necessarily a tool that opens itself up to being rigorously studied, and that does create some challenges in terms of identifying how effective it can or cannot be. But at the same time, this is where coaching wisdom and experience become valuable tools to fall back on.

If you talk to any Coach who has spent some length of time working with clients, they can anecdotally tell you that much of what we’ve talked about here is borne out amongst those people who really do make successful lifestyle changes. People who see long-lasting change are ones that typically do it for themselves above all else. They’re people who find ways to make change manageable and actionable, they find support systems, and they continually take steps forward.

Motivational Interviewing is nothing more than a tool that a Coach can use to help more people find what is manageable and actionable for them. It then helps the Coach and that person put that plan into place, knowing it has a higher chance of working because they collaborated as a partnership on that plan.

 

Tanner Baze
Director of Content