Tip #137 Health At Every Size ® and the Four Processes of Motivational Interviewing

Here we look at how the four processes of MI (Tip # 114) support a nutrition counseling session based on the HAES® paradigm.www.sizediversityandhealth.org

The quieter you become,
the more you can hear.

Ram Dass

We must ask where we are and
whither we are tending.

Abraham Lincoln

Whatever kind of counseling you are doing, it is useful to have in mind anoverall format for a session. In a traditional diet approach, this may be assessment of the client’s current diet, formation of a diet plan and helping the client work out how to do the diet plan.

When you first adopt the HAES approach, sessions can seem less structured. The four processes of motivational interviewing provide a loose structure to follow that encourages lasting change while remaining profoundly client-centered. This format encourages you to maintain the spirit of partnership, acceptance, compassion and evocation throughout. The four processes can be seen as phases. However, they do not necessarily flow in order. You shift back and forth among them as needed with a general movement toward the final process of planning.

Engagement (Tip # 115) is always first. You bring yourself into the world of the client, even if it’s painful. It can be tempting to work to bring the client into your worldview. Especially when you so strongly believe in a non-diet approach and that it is best for this person. It is possible to truly hear how much a person wants to weigh less and how painful it is live in this body while also attending to what is OK in that person’s life and looking for the signs of readiness for a HAES perspective.

Engagement includes searching for efforts toward health and strengths this person has and affirming them. It means attending to what is working now in the person’s life. Both MI and HAES are strengths-focused paradigms.

Focusing (Tip #116) is the process of guiding clients to clarify the picture of where they are headed and then to focus further on the specific steps they will take to get there. All of the OARS techniques further this process. The initial focusing may include discussion of long-term life goals and experiences with dieting. You may reflect some of these experiences and ask for elaboration. For example: “I hear you say that the times you have been on diets you find yourself enjoying life less. Tell me more about that.”

We know that a commitment to not diet is only the beginning of the HAES process. When clients decide to turn their backs on dieting, it is time to guide them toward practicing the specific behaviors that will support their new, expansive view of health. These may include gaining skill at recognizing appetite and satiety, legalizing all foods, finding new ways to cope with stress, planning days so as to avoid extreme hunger and speaking up for themselves with others. This process of focusing on just one or a few behaviors at a time is an ongoing process that you will go through again and again as you work with a person to make this significant life shift. The order in which a person works on the elements of self-care inherent in HAES will vary. You and the client will revisit the focusing process each time one behavior is becoming established and the client is ready to take on another.

Based on your experience, you may have suggestions on the most effective order to address behaviors. Your expertise here is valuable and clients know themselves in ways you cannot. In MI, the commitment to client autonomy leads you to help clients find the focus that is right for them at this time. This does not mean you withhold advice. When you believe your advice is warranted, you ask permission to provide it and then elicit a response, deferring to the client’s choices. For example: “I have an idea of how to proceed now. Would you like to hear it?” When the client says yes, you say: “Most of my clients find that beginning with attending to this appetite scale provides a strong foundation for normal eating. What are your thoughts on this?”

You may choose to give a menu of options from your experience working in the HAES manner. For example: “Now that you are feeling more confident about attending to appetite, we could bring in a new focus. What are your thoughts, or would you like some ideas from me?” If the client wants ideas, you say: “You mentioned times you turn to food to calm down and you also wanted to get better at ending meals when you have had enough. How would it be to focus on one of them?”

When a session is wandering, part of your role is to notice this lack of focus and suggest reorienting. This is a conversation about change. Is it focused enough to be effective? If not, interject: “Let’s step back for a moment and check in on how we are doing here. I’m wondering if we are talking about the most important thing today. Of all these things, which is most important to address right now?”

This focusing process strikes a balance between actively directing the client and simply following. Guiding is midway between the two and allows for both client autonomy and your expertise.

Evoking (Tip #117) occurs throughout your work. What you choose to evoke at a given time will vary. In initial sessions, you will work to evoke values, big goals, what the person knows from past experience, what has worked before to reach bigger goals, what in life is good and working well. Most people find it useful to revisit these larger goals frequently. Some clients will bring them up on their own, voicing the big picture themselves to keep focused on HAES. Other clients will need you to bring their attention back over and over to what initially motivated them to adopt the HAES approach and how far they have come. For example: “I hear your discouragement today. Might we revisit some of the things you said to me in that first visit in December? We could also take a look at how your life is now compared with last fall.”

Throughout the HAES counseling process, you will evoke a client’s creativity to choose how to proceed or to come up with what might work in a stuck place. It’s tempting to share your ideas as soon as you see the place for them. Working in an MI manner includes acknowledging that clients are the experts on their lives. This means evoking the client’s ideas and offering yours only if needed and with permission. For example: “You’ve noticed that you are really hungry when you get home from work and then tend to overeat and end up quite full. What thoughts do you have for handling this in a new way?”

Often the client will generate workable ideas. You will then simply reflect the plan you hear, perhaps guiding the client to make the plan a bit more specific. When the client comes up with a plan without you making any suggestions, the client’s self-efficacy is enhanced.

Planning (Tip #118) is the final process. People are more apt to follow through with a proposed behavior if they have a clear plan and have expressed it to someone. Planning proceeds best when engagement is good, a focus has been agreed upon, and at least some reasons to change have been evoked. Moving to planning too soon will disrupt engagement. Failing to guide toward a plan misses an important opportunity to support clients in their change process.

How to tell when a client is ready to talk about specific behavioral changes? You will hear some change talk and perhaps some tentative ideas of how to proceed. The most effective way to shift the conversation toward planning is to summarize the conversation so far and follow that with a key question. Ideally your summary will include only a few of the reasons to not move forward toward HAES and include every one of the reasons to change. For example: “You called me last week because you are sick of the dieting roller coaster and want to address your eating in a sustainable way. The diet-and-regain process has been painful and embarrassing to you. You know that big weight swings are not good for your health and at your stage in life you want to focus on health. You are willing to shift focus to health instead of weight. You know that you are a person who can make big changes because of your successful career change and you have a supportive family. You have done some reading about intuitive eating and want to give it a try. Tell me what you see as your first step in that direction?

As with all clients, you have a role in guiding them to plans that are SMART (Specific, Measurable, Achievable, Relevant and Time-bound, Tip #124). You might do this with questions such as: “How might that look this week?” “Which days will you go for those walks?” “How confident are you that you will bring your lunch?” “Tell me how that fits into your larger goal?” “When do you see yourself doing that journaling?” You can also help a client see that each plan is just for now and that this is a step-by-step process.

These four processes provide you guideposts as you converse with your client about this profound change.

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