A successful nutrition counseling session flows naturally through stages. In motivational interviewing, these are called the four processes. They are somewhat linear. A skillful counselor will circle back and move forward as needed. This deliberate shifting from one process to another is one of our most important functions as a counselor.
It is when we are in transition
that we are most completely alive.
There is a time for departure,
even when there’s no certain place to go.
A brief review of the four processes (more detail in Tips #114 – 118):
- A session always opens with engaging. It is essential to the spirit of MI and is used throughout. Engagement means working to understand what is important to the client and conveying that understanding to the client. When resistance is encountered, the counselor will need once again to attend to engagement. It may be necessary to signal this shift back to engagement.
- Focusing on a particular direction and behavior to address may be done once in a session or it may be revisited often. Sometimes the change goal is clear. More often it is not clear or may shift as the counseling progresses.
- Evoking is both an element of the MI spirit and a process. In a given session, some evoking may occur very early. For example, the counselor uses open-ended questions to evoke what is important to the client, his concerns, and what is working well and not so well. After a focus has been agreed to, change talk is evoked. This may then easily evolve into the planning process.
- In some sessions, planning proceeds naturally as the client’s change talk emerges. Using evocation, the counselor guides the client to form a concrete plan of action (Tip #124). It is often useful to deliberately ask for a shift to planning.
One of our functions is to guide the client along these processes. This can mean noticing natural transitions and more clearly remarking on them, or it can be a deliberate invitation to transition. In most cases, you will employ a summary. This has the effect of wrapping up a section of the session and reiterating what seems important in as few words as possible. You choose the themes or issues to highlight, mostly change talk (Tip #69). You can choose to place your guiding words either at the beginning of the summary or at the end of it.
In this example, the counselor realizes that engagement has been lost and asks permission to transition back to that process. It begins with acknowledging resistance. The counselor then uses a summary to guide a return to an earlier point in the session before engagement was lost.
“I get it. You feel you are being pushed to do something you are not ready for. Let’s back up here. See if I’ve got this. You are worried about your blood pressure because you’ve had one small stroke and know they are related. You are OK with taking one of the medications and want to see if you can get off the other one. How am I doing so far?”
Here, the signaling of a shift also happens at the beginning. In this case, the transition is from engagement to evoking.
“I need to get to those questions I mentioned. First, let me see if I’ve heard your main concerns. You were sent here by your doctor because of a new higher blood sugar result. You want to take this seriously because you know the things that can happen if it stays high. You realize you could use some ideas for things you can do and want to know which ones will likely be most effective. How did I do?” After confirmation that your summary is accurate, “In order to help you choose what to focus on, I need some more information from you, so here goes.…”
This example includes a summary of client experience and desired outcomes, and ends with an invitation to move on to the focusing process.
“You came in today wanting a diet plan to lose weight. We’ve explored your past experiences with such diets. You realize that even when they seem to work for a few weeks, eventually the part of you that loves to eat kicks in and you regain any weight you have lost. You see that we will need to find a way to accept and work with your food-loving part while attending to your health needs. You’ve noticed several things already. For example, that rather than putting your focus on the things you wish to eat less of, it works better to focus on what to eat more of. You also know that when you notice your hunger and fullness, you easily eat a bit less and that eating with others is more satisfying. Which of these might we focus on today?”
Here, there is a clear behavior focus, and you direct to more concrete planning.
“You have decided that you want to start testing your blood sugar because you know it will help you make some targeted changes to your meals. How will that look this week?”