Written by: Emmanuel Dubure & Kristen DiFilippo, PhD, RDN
Motivational interviewing (MI) is a client-centered counseling approach that facilitates behavior change by helping people explore and resolve ambivalence about changing their behavior (Miller & Rollnick, 2002). Originally developed in the field of addiction treatment, MI has emerged as a promising approach for supporting individuals who are ambivalent about changing behaviors that may negatively affect their health (Bischof et al., 2021). MI aims to support sustained behavior change by eliciting individuals’ intrinsic motivations and aligning change with their personal goals (Substance Abuse and Mental Health Services Administration, 2019).
MI is particularly relevant to nutrition and dietetics, where successful outcomes often depend on individuals’ readiness and willingness to modify their dietary habits and other health-related behaviors. However, applying it effectively may require understanding and considerable practice to develop the necessary counseling skills. Understanding MI’s core principles and the considerations involved in its application can therefore help dietitians use this approach more effectively to support nutrition education and facilitate behavior change.
Techniques in MI
Motivational interviewing has five techniques. These include four core techniques: Open-ended questions, Affirmations, Reflective listening, and Summarizing, known as OARS, and a fifth technique that integrates and guides the use of the other four methods.
Open-ended questions
Open-ended questions encourage clients to express their thoughts, feelings, and concerns in their own words rather than provide simple yes-or-no answers. They help establish trust, promote exploration, and allow clients to lead the conversation while the practitioner listens attentively (Miller & Rollnick, 2002). During the early phase of motivational interviewing, it is important to establish an atmosphere of acceptance within which clients will explore their concerns. In sessions with skilled MI practitioners, clients typically do more than half of the talking (Miller & Rollnick, 2002; Bischof et al., 2021)(Bischof et al., 2021; Miller & Rollnick, 2002).
Examples of open-ended questions that may be relevant to dietetics counseling include:
- “Thanks for coming in. What brings you here today?”
- “What would you like to discuss?”
- “Tell me about them.”
- “What concerns, if any, do you have about your current level of physical activity?”
- “Tell me about your weight or dieting history.”
- “What are your reasons for making this change?”
(Clifford & Curtis, 2016; Miller & Rollnick, 2002; Substance Abuse and Mental Health Services Administration, 2019)
Reflective listening
Reflective listening is a fundamental MI skill that involves more than simply hearing what a client says. It requires the practitioner to respond by reflecting the meaning or feelings underlying the client’s statements, demonstrating understanding and helping explore concerns and ambivalence about behavior change (Bischof et al., 2021; Miller & Rollnick, 2002, 2012). Examples of reflective listening in nutrition and dietetics counseling include:
- Client: “Growing up, my mom always complained about her weight. She was always dieting and making us eat her diet food.”
Reflection: “Growing up, you had to eat your mom’s diet food.”
- Client: “I feel all over the place. One minute I’m counting calories, trying to be “good” with my eating, and the next minute I’m throwing in the towel and bingeing on a pan of brownies.”
Reflection: “Dieting can feel like a rollercoaster ride”.
(Clifford & Curtis, 2016)
An RDN may even ask a question such as, “Tell me about a time when you felt your best; what were you doing then?” They can follow up this type of open-ended question with reflective listening to elicit the client’s values, strengths, and past successes.
Affirmations
Affirmation includes praise, recognition, and understanding that recognizes a person’s strengths and efforts (Bischof et al., 2021; Miller & Rollnick, 2012). They help build rapport, support self-efficacy, and encourage clients to recognize their own resources for change. Effective affirmations are genuine and specific to the client rather than general expressions of praise (Miller & Rollnick, 2002). Examples of affirmations include:
- “You’ve really come to know what your body needs.”
- “You stuck to your goal even when it was challenging to do so.”
- “You know you can do it because you’ve done it before.”
(Clifford & Curtis, 2016)
Summarizing
Summarizing involves bringing together important points a client has shared. Summary statements can be used to link together and reinforce material that has been discussed (Bischof et al., 2021; Miller & Rollnick, 2002). Summaries can also demonstrate attentive listening, reinforce key themes, help clarify ambivalence, and provide transitions between topics or stages of a counseling session (Miller & Rollnick, 2012). For example:
“It sounds like you have mixed feelings about change. On the one hand, you’re excited to start working out more often and have even recently purchased a gym membership. On the other hand, you have voiced a few concerns about working out, mainly a fear of not reaching your goal, your arthritis flaring up, and running out of steam in the evenings, making it hard to get to the gym. We’ve talked about other times in your life you’ve been active, and you recalled having more energy, sleeping better, and feeling less anxious. What did I miss?” (Clifford & Curtis, 2016, p. 137)
Eliciting change talk
Although OARS provides the core communication skills of MI, these skills alone may not be sufficient to help clients resolve ambivalence. MI also uses a guiding strategy to elicit change talk, which is clients’ own statements expressing their motivation and reasons for change. Change talk includes expressions of desire, ability, reasons, and need for change, as well as commitment, activation, and steps toward change. By eliciting and exploring these statements, practitioners help clients articulate their own motivations, strengthen their confidence, and move toward actions that align with their goals (Bischof et al., 2021; Miller & Rollnick, 2002). Adding confidence/importance rulers is one strategy that can be used to elicit change talk and explore a client’s perceived ability to change. Examples include using confidence rulers; follow-up questions include:
“On a scale from 0 to 10, how important is it for you to make this change?” A follow-up such as, “Why are you at a 6 rather than a 4?” can encourage the client to voice their own reasons for change.
On a scale from 0 to 10, where 0 means you are not at all confident and 10 means you are completely confident, how confident are you that you can begin eating 5 vegetables a day this week?” If the client responds with a 5, the practitioner can ask, “What makes you a 5 rather than a 3?” This question invites the client to identify existing motivations, strengths, supports, or prior successes.
Once a client has expressed interest and confidence in making a change, the dietitian and client can collaborate on a small, specific next step. A SMART goal can build upon what was elicited through MI, provided it reflects the client’s own priorities, language, and level of readiness.
MI can be a valuable approach for supporting readiness for behavior change across a range of health-related behaviors and for promoting treatment adherence. With appropriate training, practice, and experience, dietitians can use MI to strengthen nutrition counseling and support sustained behavior change.
References
Bischof, G., Bischof, A., & Rumpf, H.-J. (2021). Motivational interviewing: An evidence-based approach for use in medical practice. Deutsches Ärzteblatt International, 118(7), 109–115. https://doi.org/10.3238/arztebl.m2021.0014
Clifford, D., & Curtis, L. (2016). Motivational interviewing in nutrition and fitness. The Guilford Press.
Miller, W. R., & Rollnick, S. (2002). Motivational interviewing: Preparing people for change. Guilford Press.
Miller, W. R., & Rollnick, S. (2012). Motivational interviewing: Helping people change. Guilford Press.
Substance Abuse and Mental Health Services Administration. (2019). Enhancing motivation for change in substance use disorder treatment. In Treatment Improvement Protocol (TIP) Series No. 35. SAMHSA Publication No. PEP19-02-01-003. Substance Abuse and Mental Health Services Administration.
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