For two decades, motivational interviewing has been an exciting approach to behavior change counseling. Here is one definition of MI:
If you can find a path with no obstacles,
it probably doesn’t lead anywhere.
Frank A. Clark
Do not wait; the time will never be “just right.”
Start where you stand, and work with whatever
tools you may have at your command,
and better tools will be found as you go along.
“Motivational interviewing is a collaborative conversation to strengthen a person’s own motivation for and commitment to change.”
Originally developed in the field of addictions counseling, MI increasingly has been taken up by health-care providers and especially nutrition professionals. The evidence for its effectiveness is well established. The originators, William Miller and Stephen Rollnick, continue to revise the concepts and language used to describe this powerful process.
The guiding spirit of MI is unchanged. It is still based in a foundation of:
In the third edition of their textbook, coming out later this year, interesting and useful changes have been made. In this Tip, we look at one of the new concepts and how to apply it to nutrition counseling.
This change involves how to look at the overall flow of a session. Until recently, a session was seen as moving through two phases. In the first, the conversation was about importance to make a change with emphasis on evoking and supporting change talk. The session moved into phase two when the client was ready to make a plan. The process here was much like any behavioral counseling, with the counselor guiding the client to develop a specific and achievable plan for change.
Instead of this two-phase process, we can think of a session moving through four fundamental processes:
These steps are somewhat linear. However, they are not discrete phases. A skillful counselor will circle back and move forward as needed. This new view more accurately reflects what actually happens in a successful change conversation.
Engaging skills are used first. They are essential to the spirit of MI and are used throughout. When resistance is encountered, the counselor will need once again to attend to engagement. For more on the skills used in the engagement process, see Tips #102, The Very Beginning; #6, Reflecting; and #20, Unpacking Meaning.
Focusing on a particular direction and goal to address may be done once in a session or it may need to be revisited often. Sometimes the change goal is clear. More often it is not clear or may shift as the counseling progresses. This increased emphasis placed on focusing reflects a concern emerging from research that inadequate focus makes sessions less effective. Tip #4 has some ideas for helping a client to focus on a change goal.
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. The primary skill used in evoking is open-ended questioning: Tips #60 and 108. Tip #110, Encouraging Change Talk, also has examples.
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. Sometimes planning does not proceed because the client is not ready. For example, resistance may emerge when the counselor uses open-ended questions to evoke a plan for change. This necessitates going back to earlier stages to reengage and maybe refocus and evoke more change talk. Sometimes a plan can then be developed and sometimes not.
The first three processes – engaging, focusing and evoking – are always present in true MI sessions. It still may be an MI-consistent session without planning if the counselor introduced the idea of forming a plan and encountered too much resistance to proceed.
In a nutrition session, the counselor can keep in mind these four processes as a guide to stay client-centered. They are also useful as a rough format to follow to ensure the most complete and effective conversation. Some other simple formats are included in Tip #100.