Question 1

What is an example of motivational interviewing?

Dawn Clifford · Accepted Answer

According to the creators of Motivational Interviewing (MI), William Miller (https://psychwire.com/ask/profiles/shosz0/william-miller) and Stephen Rollnick (https://psychwire.com/ask/profiles/1odukxb/stephen-rollnick), Motivational interviewing is a "collaborative conversation style for strengthening a person's own motivation and commitment to change." This is done through asking open-ended questions to elicit the client's personal motivations and ideas for change along with the use of a reflective listening practice and affirmations to communicate a spirit of partnership, acceptance and compassion.
When learning about motivational interviewing, it is helpful to read sample dialogues and watch videos of the technique being used within your discipline. If you're in the field of nutrition and fitness, you can visit my YouTube channel Dawn Clifford's MI Tips (https://www.youtube.com/channel/UCJJMjsgme77ayGAtbJ0fKbw), for examples of MI being used in the nutrition and fitness setting. Here's an article in Today's Dietitian (https://www.todaysdietitian.com/newarchives/0716p48.shtml#:~:text=%E2%80%94%20Dawn%20Clifford%2C%20PhD%2C%20RD,Interviewing%20in%20Nutrition%20and%20Fitness.)with more examples.

In addition, here's a very brief excerpt from a session so that you can see how open-ended questions are used to elicit the client's personal reasons for change, along with reflective listening and affirmations to help the client hear that they have valuable skills, ideas, and plans to move forward.

Client: I need to start exercising.

Coach: You don't like how you feel when you're not active. (complex reflection)

Client: No, I don't. I feel lazy and tired. But I've been busy lately and the thought of exercise when I get home from work is just too much. I mean it's dark outside! What am I supposed to do?

Coach: You want to find ways to squeeze it in that works for you and your schedule. (complex reflection)

Client: Yes, exactly.

Coach: If you did figure out a way to consistently add more movement into your day, how do you think it would make you feel – both physically and emotionally? (open-ended question that evokes change talk)

Client: I know I'd have more energy, feel more accomplished and probably less stressed out.

Coach: You would feel like you could better manage what life throws at you. (complex reflection) Tell me more about the energy piece. (open-ended question that evokes change talk)

Client: I know when I've been active in the past I'm a nicer person to my family and I have more energy to play with my kids and things.

Coach: It gives you a mood boost that not only helps you in your day, but your family too. (simple reflection)

Client: Yes, it makes a difference.

Coach: You have a busy schedule and stress and yet you also really like how you feel when you're more active. (summary) What else motivates you to be more active? (open-ended question that evokes change talk)

Client: Well, I want to be around for my kids and I know it's good for my health. 
Coach: You care about your family and you've connected the dots that taking care of yourself helps you take better care of them – both now and in the long run. (complex reflection)

Client: Yes, I know it matters – plus if they see me doing exercises, and sports and things like that, my hope is that they will want to participate too.

Coach: You see yourself as a role model. (complex reflection)

Client: I do.

Coach: You have some great reasons for figuring out ways to fit more activity into your week – both in terms of your own health, your stress levels, and how it impacts your family. (summary) What ideas do you have for realistic ways to add movement back into your days? (open-ended question eliciting the clients' ideas for change.)

Question 2

What is it about MI that makes it well-suited to nutrition and fitness counseling?

Dawn Clifford · Accepted Answer

Ambivalence, or having mixed feelings about change, is a normal part of the change experience. We all hold a lot of ambivalence when it comes to our self-care patterns. In terms of making changes related to eating and physical activity, people often perceive that changes in these areas require a very scarce commodity in our society – time! Clients often think that excessive amounts of time, sweat and misery are required to make changes related to nutrition and fitness. They think that they have to be in pain for exercise to "count" or that the food that nourishes the body is boring or tasteless. That's because folks often think very black-and-white when it comes to their health behaviors – I'm on a diet or I'm off my diet.

MI can be used to explore previous patterns and what approaches have worked in the past and what approaches haven't worked in terms of long-term sustainability. I think it's helpful to invite clients to consider very small, realistic changes that can make a big difference in not just their health but how they feel during the day.

Clients don't have to completely revamp their eating patterns, ditch pleasurable foods, or commit to an intense workout regimen in order to experience the benefits of change. For example, a simple change like bringing an afternoon snack to work can help someone have more brain power and less fatigue in the afternoon. Or, going for a 15-minute walking break can help reduce stress and improve focus. While both of these changes require a little bit of time, clients often find that the small chunks of time are worth the immediate benefits they experience in the moment. I've found it's freeing for clients to hear that they can make small changes that can make a big difference.

Both with physical activity and nutrition changes, there are many opportunities to invite clients to tune into the intrinsic benefits of change, using open-ended questions. When clients can notice that they feel better emotionally and physically when they make the change, they are much more likely to stick with that change long term. Questions like these can be especially powerful:
- What did you notice on the days you were successful with that change?
- In the past, when you made a change like this, how did you feel immediately afterwards?
- How would a change like this impact your mood? Stress? Energy level?

Question 3

How do you motivate a client who is depressed and ambivalent about exercise/stuck in non-activity to explore movement that will likely help them feel better?

Dawn Clifford · Accepted Answer

There are two primary ingredients needed to increase motivation: importance and confidence. Clients will consider change when they believe the change is important to them and when they have confidence in their ability to make the change.

Here are 3 ways to build importance:

* Explore your client's values and goals. More specifically, invite your client to consider how the change they're considering aligns with their goals and values. Questions you could ask include:
- What are the things that are most important to you in this season of your life?
- What do you value most in your life? How does this change you're considering align with those values?

* Ask the client about their personal reasons, desires, abilities and needs for change. This is known in MI as change talk. There are many different types of questions that can elicit change talk. Here are a few:
- Why are you considering this change?
- How would making this change make your life better?
- What are some other benefits of making this change that maybe you haven't thought of yet?
- If you did make this change, how would things be different for you a year from now?

*Reflect on your client's change talk. When the client answers your evoking questions, use a reflective listening response to reflect the change talk back to them. This helps the client to hear themselves and they start to realize they have good reasons for change. Reflective listening is a key skill in MI. A key strategy for boosting motivation is to have clients hear their personal sources of motivation spoken back to them. Clients often have "ah-ha" moments and will say things like, "I didn't realize until now that I felt that way." Plus, when you use reflective listening, it shows that you're really trying to understand what your client is experiencing – you're simply being a good listener.

Here are 3 ways to build confidence:

* Invite your client to think of very small "first step" goals. Confidence comes with success. We want our clients to feel successful with change and they will feel successful with change when they set teeny-tiny goals that are achievable and then they are able to follow through with them. An example of a very small goal that can help get the ball rolling is like, "find 3 new recipes to try". This may seem insignificant in terms of immediately impacting your client's health, but it's an important first step and being successful in those initial small steps can lead to bigger successes later on.

* Invite your client to come up with change strategies. Clients will feel more empowered and in control if we tap into their ideas. They know themselves best and what will work and not work in their lives. They are the experts on their routines and patterns. You can ask questions like: "What ideas do you have for getting started with this change?" Then help them think through all of the pieces of the change – the when, where, who, how, and how often. This will help them set a clear vision for the week ahead.

* Explore potential barriers to making the change. It helps to troubleshoot within a session and explore what might come up. See if the client has ideas for how they'll overcome those barriers. If they don't, then you can ask permission to share a few. They'll have more confidence in their ability to change if they've come up with a plan a, b, and c.

Question 4

In your experience, is it easier for people to make fitness or nutrition changes? Where is the best place to start with clients?

Dawn Clifford · Accepted Answer

The best place to start is the change the client is most ready to make. This varies from person to person. When clients come up with multiple areas in their lives where they'd like to make a change, it's helpful to invite the client to narrow it down to one change focus at a time. So, if a client shared that they were wanting to "get healthier," I would first invite them to define that. What does it mean to be healthier, in their opinion? What are the behavior changes that they feel would best support their health? And then from there, what changes do they feel most interested in exploring in that session that would enhance their quality of life? If the client is interested in multiple changes, it's important to discuss how those other changes might be addressed in the future. Making a change is hard, so it's helpful to simplify the process by focusing on one change at a time.

Question 5

Is motivational interviewing something that can be taught to fitness trainers and coaches?

Dawn Clifford · Accepted Answer

Yes, personal trainers or fitness trainers can really enhance the services they provide by becoming proficient in motivational interviewing. Personal trainers have a very specific knowledge that can help clients reach their fitness goals. They can certainly be effective in helping the client during fitness sessions in terms of using correct form and doing the appropriate number of reps. However, they can make an even bigger difference in their client's health patterns long-term if they use motivational interviewing to explore their long-term goals and ideas for sustaining physical movement long after their personal training sessions are over.

In terms of coaching, this is another area where motivational interviewing can enhance the service provided. Guilford Press published the book Coaching Athletes to Be Their Best: Motivational Interviewing in Sports (https://www.guilford.com/books/Coaching-Athletes-to-Be-Their-Best/Rollnick-Fader-Breckon-Moyers/9781462541263) with Stephen Rollnick as one of the authors. This book is published by Guilford Press, who also published our book (https://www.amazon.com/Motivational-Interviewing-Nutrition-Fitness-Applications/dp/1462524184/), and is a reputable publisher in the MI arena. Imagine how much more effective coaches can be in motivating their athletes by using MI to enhance their communication. These approaches are so different from former coaching styles where coaches threaten and yell at their athletes to try to motivate them. MI can really turn coaching on its head and be so much more effective. As a former competitive athlete, I really appreciate this new application of MI and I look forward to following how this changes sports moving forward.

Question 6

What should be avoided in motivational interviewing?

Dawn Clifford · Accepted Answer

In motivational interviewing, the key is to align your approach with the Spirit of MI, which includes partnership, acceptance, compassion, and evocation. In essence, the goal is to hold space for your client to talk through health-supporting changes that are free from judgment, pressure, and coercion. Here are some specific counseling approaches to avoid:

* Avoid giving the client unsolicited advice. Instead, check to see if your client has ideas for overcoming their own challenges and then, if they can't think of any, you can ask the client's permission to share your ideas.

* Avoid telling the client what works for you. You may have discovered some strategies that have worked for you in changing your own health patterns, but that doesn't mean those same strategies will work for your client. Plus, in sharing your personal self-care patterns, you give off the vibe that you have perfect habits and that change is easy. In reality, change can be hard, and you may hold privileges that are not shared by your client. When you have strategies that you think might help, remember to check with the client first to see if they are in need of suggestions and frame them as "strategies that have worked for other clients" instead of framing them as strategies that have worked for you.

* Avoid using imperatives like "should". When you "should" on your clients you are making an effort to persuade them towards change. In motivational interviewing, the goal is to avoid persuasion and instead ask your client what they'd like to do.

* Avoid offering an idea in the form of a question. In an attempt to "soften" the way we communicate with clients, it's tempting to replace "shoulding" with offering ideas in the form of a question. An example of this might be: "Have you thought about inviting a friend to join you?" In this example you are giving unsolicited advice and putting that advice in the form of a question, which still makes it persuasive in nature. Instead of offering advice in the form of a question, ask the client what ideas they have and if they don't think of the friend idea, you can ask permission to share it: "I can think of one strategy that has helped previous clients. I can share it with you if you'd like. However, you know yourself best, so feel free to disregard this idea if you don't think it will work for you."

Question 7

Can you do motivational interviewing on yourself to make exercise and eating changes?

Dawn Clifford · Accepted Answer

There are a few books out there that refer to principles of motivational interviewing but are more in the realm of self-help. In fact, one of the creators of motivational interviewing, William Miller, recently published the book On Second Thought: How Ambivalence Shapes Your Life (https://www.guilford.com/books/On-Second-Thought/William-Miller/9781462547500). Another book in the realm of "MI-ing yourself" is Finding Your Way to Change (https://www.guilford.com/books/Finding-Your-Way-to-Change/Allan-Zuckoff/9781462520404) by MI Trainer Allan Zuckoff. Both books are published by Guilford Press.

Question 8

I'm curious about how effective intuitive eating is given the time it takes for satiety signals to reach the brain? Especially for people who experience disembodiment and are uncomfortable feeling in their body? Thank you for taking questions.

Dawn Clifford · Accepted Answer

Intuitive eating is highly researched (https://www.intuitiveeating.org/resources/studies/) and well established as an effective approach for those wishing to make peace with food. You are correct that it takes several minutes to experience satiety and this is an important point to share with clients who are trying intuitive eating for the first time. Clients might find it helpful to slow down the eating experience and take some time to make the decision about eating more or going back for a second serving. You can invite clients to enjoy the company of those they are with, sip some water, and revisit their decision to continue the meal in 5-15 minutes, after allowing that satiety cue to settle in. And for those eating alone, they can move on to their next activity and return to eating if they find themselves not fully satisfied shortly after finishing their meal.

Like most things, intuitive eating takes practice, and so over time I find that individuals start to be able to predict their fullness levels in terms of what it is in the moment and what it will feel like in 15 minutes when that final satiety level settles in. I encourage clients to experiment with this and it's important to do so with compassion and curiosity instead of judgment, viewing each eating experience as an opportunity to play around with eating, satisfaction, and fullness.

The concept of Intuitive Eating (https://www.intuitiveeating.org/), which was founded by dietitians Evelyn Tribole and Elyse Resch, goes beyond just using fullness cues to find a comfortable stopping place during the eating experience. In fact, there are 10 principles to intuitive eating (https://www.intuitiveeating.org/10-principles-of-intuitive-eating/). It might be helpful for some clients to explore all of the intuitive eating concepts since they all work together. This might take place over several sessions, or the practitioner may explore if the client is interested in listening to a podcast or reading the Intuitive Eating book in conjunction with the nutrition counseling they receive.

To address the other part of your questions, it's likely that someone who experiences disembodiment may need to work with a therapist to unpack that and explore sources, previous trauma, triggers, and coping mechanisms before embarking on an intuitive eating journey.

Question 9

Is a non-diet approach on its own enough to help a client improve their health and fitness, or are food and exercise programs necessary at some point?

Dawn Clifford · Accepted Answer

It's important to approach each client as an individual with various lived experiences and unique needs. The goal of nutrition and physical activity counseling is to help clients discover ways of eating and movement that support physical health and also emotional well-being.

It's important to take into consideration changes that are possible for the client, considering common barriers like access to grocery stores with fresh produce, which is challenging in more rural settings, access to safe neighborhoods for physical activity, and access to healthcare. Some clients may not be able to make the changes they'd like to make if they don't have sufficient resources. Therefore, a non-diet practitioner provides very individualized care and takes into account the client's individual physical and emotional health issues, taste preferences, culture, and access to resources. It's a very holistic approach.

Certain "food and exercise programs" may support clients' physical health but fail to support their emotional health or individual needs, which could take them down a path of disordered eating (restriction/binge behavior, for example) and yo-yo dieting. Trying to follow restrictive and unpleasant "food and exercise programs" can be very stressful, and by adding stress, we're not improving a person's health and well-being, we're making it worse. Therefore, it's important to really take the time to explore with your client their current relationship with food, their previous dieting patterns and their current physical health issues before deciding the best next steps on their journey.

A non-diet approach refers to helping the client adopt individualized changes that support health and well-being but take the focus off of weight. For example, a higher-weight client may have elevated blood pressure, and a weight-centric dietitian would try to help the client lose weight, even though studies show that most clients regain the weight within 2-5 years. A non-diet dietitian would explore which changes the client is interested in making that could lead to lowering blood pressure and then work with the client to find small sustainable changes like adding more fruits and vegetables, physical activity or stress management. The focus would be on pleasurable forms of self-care that are of interest to the client. This approach removes the shame clients often experience related to their weight and centers on the client's specific health concerns. A non-diet practitioner will also advocate for improving the social determinants of health, such as ensuring people with high blood pressure have access to quality health care, medications, education, and food.

Question 10

What does the latest research say about weight and health, and can you truly be “healthy at every size”?

Dawn Clifford · Accepted Answer

The latest research about weight and health says that weight is a lousy predictor of health outcomes and mortality. Health behaviors such as physical activity, eating fruits and vegetables, moderate alcohol intake and not smoking are better predictors than weight. And, you can't tell a person's health-supporting behaviors based on their weight or appearance, so it's important to never make assumptions about your clients' patterns. It's important for those in the nutrition and fitness industry to take a step back and look at a very complex picture of health – one that goes beyond individual behaviors and considers factors like genetics and the Social Determinants of Health (https://www.cdc.gov/socialdeterminants/index.htm). In addition, higher weight clients often experience weight stigma (https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-018-1116-5?fbclid=IwAR17UuHTs18rl3JEjFiQK4crFgLGJA0-RqrtUr_HCQxUSZkGI0jowdCmrb8), which increases the stress hormone cortisol and is linked to poor mental health. Therefore, the previous associations between weight and health documented in the scientific literature may be explained by these other factors.

The term Health At Every Size® was trademarked by the Association for Size Diversity and Health (https://asdah.org/health-at-every-size-haes-approach/), and it is a social justice movement that "affirms a holistic definition of health, which cannot be characterized as the absence of physical or mental illness, limitation, or disease. Rather, health exists on a continuum that varies with time and circumstance for each individual. Health should be conceived as a resource or capacity available to all regardless of health condition or ability level, and not as an outcome or objective of living. Pursuing health is neither a moral imperative nor an individual obligation, and health status should never be used to judge, oppress, or determine the value of an individual."

Therefore, the term Health At Every Size (HAES) is not synonymous with "healthy at every size". The term does not address whether a person can be healthy at different body weights. People of all sizes struggle with illness and disease in many forms. Instead, the term addresses that all individuals, regardless of size, deserve access to healthcare and support to make health-supporting changes if they choose (while also acknowledging that the pursuit of health-supporting behaviors is not a moral imperative).

The HAES movement is about providing weight-inclusive care, meaning that weight is not a focal point for medical treatment or nutrition and fitness coaching. In addition, weight-inclusive non-diet practitioners like myself believe that everyone deserves access to non-stigmatizing care and that BMI does not reflect health status, health practices or moral character.
For more reading about HAES misconceptions, visit: https://nutritionbycarrie.com/2021/01/haes-misconceptions.html

For more information on the scientific evidence in support of weight-inclusive approaches, visit: https://downloads.hindawi.com/journals/jobe/2014/983495.pdf?utm_source=convertkit&utm_medium=email&utm_campaign=how+do+you+know+what+to+believe+about+diets%3F%20-%206452665

Motivational Interviewing in Nutrition and Fitness

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