Tip #136 Health At Every Size ® and the Skills of Motivational Interviewing

This Tip continues to explore the Health At Every Size ® paradigm and how it fits with motivational interviewing.

It is not because things are difficult that we do not dare;
it is because we do not dare that they are difficult.


We must be willing to get rid of the life we’ve planned,
so as to have the life that is waiting for us.

Joseph Campbell

Shifting to a HAES approach involves profound changes for our clients. These changes include attitudes, priorities and values as well as behaviors. MI skills are uniquely designed for helping people who are considering profound change. They include an assumption that change is not easy and that taking time and care with the process will be more satisfying. We will look at examples of how the basic MI skills might sound with our clients. In the next Tip, to put it all together, we will look at the four processes that form a motivational interview.

The basic skills go by the acronym OARS: Open questioning, Affirming, Reflective listening and Summarizing. Here are examples of how OARS might be used in a HAES approach:

Open questions (Tips #60, 108) allow you to invite the client who is focused on weight to see a bigger picture. For example:

  • “If we are successful here, how do see your life in the future?”
  • “Tell me about your dreams for your life.”
  • “Tell me more about how that would look.”

To bring out what the client already knows about the downside of dieting:

  • “Tell me your experience with diets.”
  • “And then what happened?”
  • “Tell me more about what it feels like when you are on a diet.”

To focus on strengths:

  • “Tell me about times you have made permanent changes in taking care of yourself.”
  • “How did you do it? What worked?”
  • “What self-care behaviors are second nature for you?” Some clients may not understand this question and may need examples, such as brushing teeth or putting on lotion.

To guide clients to the next step to take:

  • “How might you practice that this week?”
  • “What might be your first step toward that goal?”
  • “How do you see yourself using this appetite scale (or journal)?”

What you choose to affirm (Tip #63) has a profound effect on your clients. To affirm, you notice strengths or efforts and reflect them back. Sometimes you reframe what you have heard to pick out a larger strength. Examples in a HAES model:

  •  “You’ve thought a lot about this since our last visit. You are someone who takes things to heart.”
  • “You notice what is going on in your life and how it affects your eating.”
  • “You know which foods tend to satisfy you and which ones usually don’t.”
  • “You are someone who learns from your experience.”
  • “You are capable of distinguishing between eating for appetite and for emotions.”
  • “You already have the skill of scheduling self-care actions in your phone.”
  • “You have lots of habits in place that contribute to your health.”
  • “You are someone who cares about both your physical and mental health.”
  • “When you set your mind to something, you follow through.”

As in any type of counseling, careful reflecting (Tips #6, 95) encourages the client to continue the thought process forward. You could notice change talk that moves in the direction of HAES behaviors and reflect it. (Tip #69 has more on how to recognize change talk.) You could focus on HAES-consistent outcomes as they emerge. This might sound like: “You like this feeling of being more relaxed when you think about food.” Or, “You find your mind functions better at work since you have given yourself permission to have a snack in the midmorning.”

Complex reflections can highlight client insights and guide them toward more. For example:

  •  “You’ve noticed that the diet ‘voice’ in your head gets louder when you have been around that friend.”
  • “You dislike the feeling of guilt when you eat something ‘forbidden’ and see that giving yourself permission to eat anything will allow that to fade away.”
  • “You like this person you are becoming and continue to search for ways to like her more.”

Summarizing (Tips #72, 119) allows you to reflect the clients’ main points again. You also use summaries to segue into asking for focus or to wrap up and remind the clients what they plan to do this week. One format for summaries:

  • Introduction: Reflect something about the situation as you heard it from the client.
  • Include some things you heard are important to this person.
  • Reflect again some strengths and efforts.
  • Repeat any ability statements you heard.
  • Wind up with the plan as stated by the client (if there is one).
  • Ask for confirmation or a key question that will move you to the next process.

Here is an example of a summary at the end of a first session:

“So, Eric, you came in here today very concerned about this new diagnosis of high blood pressure and figured that I would tell you to stop eating everything you love and to lose weight. You are someone who is proud of your health and want to do all you can to avoid using medication to bring down your blood pressure. Being around for a long time to provide for your family is a bedrock value for you. You are an organized person and know that you have made some health changes in the past that have become habits. You have been on rigid diets before and have learned from them that they backfire. You are ready to use this journal to take a good look at how your eating goes now. You’ve decided to fill out these three columns for now. Next time we will see what you have learned from these observations and will look more at what you can do for your blood pressure that does not involve rigid dieting. What have I missed?”

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