Dietetic Guidance and counseling

Instructor: Jacent Kamuntu Asiimwe (PhD)

Motivational Interviewing (MI)
The definition of Motivational Interviewing (MI) has evolved and been refined since
the original publication on its utility as an approach to behavior change by William
Miller in 1983. Through empirical research, the fundamental principles and
methodologies of MI have been applied and tested in various settings and research
findings have demonstrated its efficacy.

MI focuses on exploring and resolving ambivalence (a state of indecisiveness) and

centers on motivational processes within the individual that facilitate change. The
method differs from coercive or externally driven methods for change. MI does not
impose change (that may be inconsistent with the person's own values,
beliefs or wishes) but rather supports change in a manner compatible
with the person’s own values and concerns.

MI can be defined in many ways and below are some of the definitions;
 A collaborative person-centered form of guiding to elicit and strengthen
motivation for change.
 A lay person’s definition (what it is for): MI is a collaborative conversation to
strengthen a person’s own motivation for commitment to change.
 Technical therapeutic definition: MI is a collaborative goal-oriented method of
communication particular attention to language of change. It is designed to
strengthen the individuals’ motivation for and movement towards a specific
goal by eliciting and exploring the person’s own argument for change.
 A pragmatic practitioner; MI is a person-centered counselling method that
addresses the common problem of ambivalence (uncertainity) about change

The MI Approach
MI is grounded in a respectful statnce with focus on building rapport with the client in
the initial stages of the counseling relationship. A central concept of MI is identification,
examination and resolution uncertainty about changing behavior. Ambivalence is seen
as a natural part of the change process. A good counselor must be attuned to the client
ambivalence and readiness to change and thoroughly utilizes techniques and strategies
that are responsive to the client.
Dietetic Guidance and counseling
Instructor: Jacent Kamuntu Asiimwe (PhD)
The Spirit of MI
MI is characterized by a particular “spirit” or “way of being” in context with
interpersonal relationship and techniques employed. The spirit of MI is based on 3 key
elements: collaboration, evoking (drawing out) and autonomy.

• Collaboration (vs. Confrontation)

Collaboration is a partnership between the counselor/therapist and the client
grounded in the clients’ point of view or experiences. This is in contrast to situations
where the counselor assumes the “expert” role at times confronting the client and
imposing their perspective on the clients’ behavior.
Collaboration builds rapport and facilitates trust. This does not mean that the
counselor automatically agrees with the client about the nature of the problem or the
appropriate changes. The process is focused on mutual understanding and not on the
counselor being right although the client and counselor may see things differently,

• Evocation (Drawing Out, Rather Than Imposing Ideas)

In the MI approach the counselor draws out the clients own thoughts and ideas rather
than imposing own opinion. Here the idea is that motivation or commitment to
change is more powerful and durable when it comes from the client. No matter
what reasons the counselor may give to convince the client about the need for change,
lasting change is more likely when the client discovers their own reason and
determination to change. The counselor’s job is to “draw out the person’s own
motivations and skills for change and not to tell them what they should or should not
do.

• Autonomy (vs. Authority)

MI recognizes that the true power for change lies within the client. Ultimately, it is
up to the individual to follow through with making changes to happen. This is
empowering to the client and gives them responsibility for their actions. The
counselor is there to reinforce that there is no single “right” way to change but rather
multiple ways. Clients are therefore encouraged to take the lead in developing a
menu of options to achieve the desired change.
Dietetic Guidance and counseling
Instructor: Jacent Kamuntu Asiimwe (PhD)

The Principles of MI
There are four major principles of MI expounded on below;

 Express Empathy
This involves seeing the world through the clients ‘eyes, thinking about things the
way the client thinks and feeling the same way as the client feels. This helps the
client to feel that they are heard and understood therefore making them more likely
to honestly share their experiences in depth. The client should experience the
counselor as able to see the world/problem as they see it.

• Support Self-‐Efficacy
MI is a strengths-based approach that believes that the clients have within
themselves the capabilities to change. A client’s belief that change is possible (self-
efficacy) is needed to instill hope about making those difficult changes. Often clients
have previously tried and failed or been unable to maintain the desired change
hence creating doubt about their own ability to succeed. In MI the counselor
supports self-efficacy by focusing on the previous successes and highlighting skills
and strengths that the client already has.

 Roll with Resistance

From and MI perspective, resistance occurs when the client experiences a conflict
between their view of the problem or solution and the views of the counselor
about the same or when the client feels that their autonomy or freedom is being
impinged upon. In MI a good counselor avoids resistance by not confronting the
client. However, when resistance occurs the counselor must work to de-escalate or
avoid negative interactions by “rolling” with it (resistance). Actions and/or
statements that show resistance should remain unchallenged especially during the
early counselling relationship. By rolling with resistance one is able to disrupt any
“struggle” that may occur so that the session does not resemble an argument
between the client and counselor. The MI value of leaving the client define the
problem and develop own solutions often leaves little room for resistance. A
frequently used metaphor is “dancing” rather than “wrestling” with the client.

• Develop Discrepancy
Dietetic Guidance and counseling
Instructor: Jacent Kamuntu Asiimwe (PhD)
Motivation to change occurs when people perceive a mismatch between “where
they are and where they want to be”. The counselor works to develop this by
helping clients examine the discrepancies between the current
circumstances/behavior, their values and future goals.
Clients are more likely to change what they realized that their current
situation/behaviors place them in conflict with their values or interfere with
their goals

MI Skills and Strategies

The MI “Spirit” aims at eliciting client change talk and commitment to change. Change
talks involves statements or non-verbal communications indicating that the client may
be considering to the possibility of change. The table below shows the stages of change a
person may go through before finally making and maintaining change.

OARS:
Often called the micro-counselling skills , OARS is a brief way to remember the basic
approaches used in MI. It stands for Open-ended questions, Affirmations, Reflections
and Summaries. These are core skills a counselor employs to move the process forward
by establishing an alliance with the client to elicit change,

• Open-ended questions: Are those that not easily answered with a yes/no or short
answer. The open-ended questions invite elaboration and deeply thinking about an
issue. Although closed questions may sometimes be valuable e.g when collecting specific
information during assessment, open-ended questions create forward momentum used
to help a client explore the possibility of change.

• Affirmations: These are statements that recognize the client strengths and assist in
building rapport and help the client to see themselves in a different light (positive).
These affirmations help the client to feel that change is possible even when previous
efforts have been unsuccessful. Affirmations should be genuine as they are a key element
in facilitating the MI principle of supporting self-efficacy.

• Reflections: This is sometimes called reflective listening and is perhaps the most
crucial skill in MI. It has two primary purposes, a) to bring to life the principle of
expressing empathy. By careful listening and reflective responses the client is able to
feel that the counselor understands the issues from their perspective. B) Reflective
listening is also a core intervention toward guiding the client towards change
supporting the goal-directed aspect of MI. The counselor guides the clients to resolve
Dietetic Guidance and counseling
Instructor: Jacent Kamuntu Asiimwe (PhD)
ambivalence by focusing on the negative aspects of the situation and the positives of
making change

• Summaries: These are special types of reflections where the counselor recaps
what transpired during the session(s). Summaries communicate interest and
understanding and call attention to the important elements of the discussion.
They usually highlight both sides of t the client’s ambivalence about change and
promote the development of discrepancy by strategically selecting what
information should be included or excluded.

Change Talk

Change talk is defined as statements by the client revealing the consideration of,
motivation for, or commitment to change. The more someone talks about change the
more likely they are to change. Different types of change talk can be described using the
DARN-CAT.
Preparatory Change Talk
Desire (I want to change)
Ability (I can change)
Reason (It is important to change)
Need (I should change)

Implementing Change Talk

Commitment (I will make changes)
Activation (I am ready, prepared and willing to change)
Taking Steps (I am taking specific actions to change)

Strategies for evoking change talk

There are specific therapeutic strategies that are likely to elicit and support “change talk”
in MI. Some of these are suggested below.

1. Ask Evocative questions: Use open questions, the answer to which is likely to be
change talk.
2. Explore Decisional Balance: Ask for the pros and cons of changing and not
changing/staying the same.
3. Good things not-so-good things: Ask about the positives and the negatives about
the target behavior.
4. Ask for elaborate examples: When a change talk theme emerges, ask for more
details. “In what ways, tell me more, when was the last time that happened, what
does that look like?” etc.
 Dietetic Guidance and counseling
Instructor: Jacent Kamuntu Asiimwe (PhD)
5. Look Back: Ask about the time before the target behavior/situation emerged. How
were things better, different?
6. Look Forward: Ask what may happen if things continue the way they are. Try
the miracle question, if you were 100% successful in making the changes you want,
what would be different? How would you like your life to be 5 years from now
7. /Query Extremes: What is the worst thing that may happen if you don’t make the
change, what is the best thing that may happen when you make the change?
8. Use Change Rulers: Ask: on a scale of 1-10 how important is it to you to change
the specific target behavior? where 1 not at all important and 10 is extremely
important. Follow with the question and why are you at----------- (whatever number
stated), what might happen if you move from ------- to ------?
Alternatively, you could also ask “How confident are that
you could make the change if you decided
to do it?”
9. ExploreGoals and Values: Ask what the person’s guiding values
are. What do they want in life? Ask how the
continuation of target behavior fits in with the person’s goals or values.
Does it help realise an important goal or value, or interfere with it or it is irrelevant.
10. Come Alongside: Explicitly side with the negative (status quo)
side of ambivalence. “Perhaps ___is so important to you that you
won’t give it up, no matter what the cost.”

Stages of Change: A Model for Nutrition Counseling

Stage Description Goal Strategies
Precontemplation Is unaware of problem Increase awareness of Create supportive climate for
and hasn’t thought need for change. change.
about change.
Personalize information Discuss personal aspects and
Has no intention of on risks and benefits. health consequences of poor
taking action within eating or sedentary behavior.
the next 6 months.
Assess knowledge, attitudes,
and beliefs.
Build on existing knowledge.
Contemplation Intends to take action Increase motivation and Identify problematic behaviors.
within the next 6 confidence to perform
Prioritize behaviors to change.
months. the new behavior.
Discuss motivation. Identify
barriers to change and possible
solutions.
Suggest small, achievable
steps to make a change.
 Dietetic Guidance and counseling
Instructor: Jacent Kamuntu Asiimwe (PhD)
Preparation Intends to take action Initiate change. Assist in developing a concrete
within the next 30 days action plan.
and has taken some
Encourage initial small steps to
behavioral steps in this
change.
direction.
Discuss earlier attempts to
change and ways to succeed.
Elicit support from family and
friends.
Action Has changed overt Commit to change. Reinforce decision.
behavior for less than 6
Reinforce self-confidence.
months.
Assist with self-monitoring,
feedback, problem solving,
social support, and
reinforcement.
Discuss relapse and coping
strategies.
Maintenance Has changed overt Reinforce commitment Plan follow-up to support
behavior for more than and continue changes/ changes.
6 months. new behaviors.
Help prevent relapse.
Assist in coping, reminders,
finding alternatives, and
avoiding slips/relapses.
Source: Adapted from Glanz K, Rimer T. Theory at a glance: a guide for health promotion practice. Bethesda, MD:
National Institutes of Health, National Cancer Institute; 1995 and Sandoval WM, Heller KE, Wiese WH, Childs DA.
Stages of change: a model for nutrition counseling. Top Clin Nutr 1994;9:65-69.

References

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Miller, W.R. & Rollnick, S. (2010). What’s new since

MI-‐2? Presentation at the International Conference on
Dietetic Guidance and counseling
Instructor: Jacent Kamuntu Asiimwe (PhD)
Motivational Interviewing (ICMI). Stockholm, June 6, 2010.
Accessed at http://www.fhi.se/Documents/ICMI/Dokumentation/June- ‐6/Miller-‐and-‐
Rollnick-‐june6-‐pre-conference-‐workshop.pdf

Miller, W.R. & Rollnick, S. (2010). What makes it

Motivational Interviewing? Presentation at the International
Conference on Motivational Interviewing (ICMI). Stockholm,
June 7, 2010. Accessed at
http://www.fhi.se/Documents/ICMI/Dokumentation/June- ‐7/Plenary/Miller-june7-‐
plenary.pdf.

Rollnick, S., & Miller, W.R. (1995). What is

motivational interviewing? Behavioural and
Cognitive Psychotherapy, 23, 325-‐334.