Associate Director, Amy Rauworth

Promoting physical activity, healthy eating, and other healthful lifestyle behaviors is not always the easiest thing to sell to our clients. No doubt, we are passionate professionals who truly believe in what we are preaching, but at times that passion can lead to an authoritarian approach to the advice that we deliver. Rather than selling, preaching, or dictating the change that must take place, we can empower and engage our clients to set their own agenda for change and in doing so, allow them to work through their ambivalence to change and explore their own strategies for overcoming barriers. To learn how to roll with resistance and elicit change talk read this month's FITT column.

If you are like me, when you read the preceding paragraph and first thought about allowing your clients to set the agenda, a small part of you felt uneasy, or you may have even said 'yeah right,' out loud. If you were to ask my husband about me, he might say I can be bossy at times and tend to over-plan activities for everyone. Keeping that in mind (even though I think many husbands might describe their wives in similar fashion), the transformation from my typical didactic approach to a more egalitarian, empathetic 'way of being' has been a leap of faith on my part and a benefit for my husband especially!

Approximately one year ago, all staff, including myself, at the Center on Health Promotion for People with Disabilities attended a training seminar on Motivational Interviewing (MI) by Charles H. Bombardier, PhD, a Professor from the Department of Rehabilitation Medicine at the University of Washington School of Medicine. Since then, I have slowly integrated the spirit of MI into my interactions with clients and in daily life. It is not easy for me, I must admit, but with each interaction I learn more and I see the benefits. According to Dr. Bombardier, 'The respectful approach of Motivational Interviewing transcends culture and age and empowers people with disabilities to take control of their lives.' MI aligns itself well with the social model of disability. Dr. Bombardier also suggests 'MI negates the fixer mentality of telling people what to do without asking, not giving choices, and not engaging the person in the change process.' According to founders Miller and Rollnick, MI is defined as a directive, client-centered approach for eliciting behavior change by helping clients explore and resolve ambivalence. This counseling style includes the use of reflective listening, rolling with resistance, agenda-setting, and eliciting self-motivational statements and change talk. The effectiveness of MI has been documented in numerous randomized trials. It has been found most effective for individuals who are initially less ready to change their behavior. The basic principle of MI associates successful behavior change with motivation, not information. Typical public health messaging often focuses on the risk of the continued behavior. For example, the popular smoking commercials that associated smoking with death through the visualization of body bags were meant to shock people into realizing that smoking is a deadly habit. MI allows individuals to openly discuss the positive and negative aspects of changing or not changing the behavior in a non-judgmental environment. By expressing their own opinions and plans, people are more likely to accept and take action on ideas that are generated through self-discovery.

It is important to begin by understanding which stage of change your client is in and the concept that this stage may continually fluctuate throughout the session or intervention. For example, many persons are initially ambivalent about changing. This may seem like resistance ('yes, but...') to the health professional. Using MI, the health professional recognizes ambivalence and avoids arguing for change because this tends to amplify the ambivalence. Instead, MI counseling uses open-ended questions, affirmations, empathy and reflections to give the person room to seriously explore and resolve their ambivalence. In other situations where the individual is simply not ready for change, MI teaches us not to make things worse by confronting the individual and worsening their resistance. In these situations, MI provides the practitioner with ways to raise doubts about not changing and to touch on any discrepancies between the person's behavior and their core values or goals in an accepting environment. We can also offer the possibility of future assistance when the client is ready.

In MI, the client sets the agenda. This means that he or she will choose the topic for discussion. If you are working in a specific field such as exercise or nutrition, it is acceptable for the client to choose not to discuss these areas; however you can guide him or her through a menu of options if your intervention or program requires this. A framework for exchanging information when utilizing MI is 'elicit-provide-elicit.' A session might begin with the practitioner eliciting the person's understanding and information needs. At this point, it is appropriate for the practitioner to ask permission to provide information, feedback, or advice, which is always given in a neutral manner. Next the practitioner would again elicit from the client the personal relevance of this discussion by asking open-ended questions such as, "How do you make sense of all of this?" The MI practitioner will roll with resistance and never confront or argue with the client. Instead, the opportunity can be used to express empathy, understanding, and affirmations. Shifting the focus or reframing failures as positive efforts can encourage the individual to work through his or her ambivalence.

To elicit change talk, the MI practitioner can utilize the importance/confidence rulers that assess the desire and efficacy for change. This technique begins by asking the question, 'On a scale from 0 to 10, how important is it for you to make this change (0='not at all' and 10='extremely important')? If there is a desire to change, a second question is asked; 'Again on a scale from 0 to 10, how confident are you that you can make this change (0='not at all confident' and 10='extremely confident')? From these answers, additional probing questions utilizing a numeric response can be asked, such as:

1. Why did you not choose a lower number like 3 or 4?
2. What would it take to get you to a higher number?

Reflective listening is an additional tool that can be important in the self-discovery process. It can be used to guide the individual to confront his or her own inconsistencies in thought and action. Simple reflections should be phrased as a statement and not a question. For example, 'You don't see a way to fit exercise into your schedule.' The inflection at the end of a statement goes down and can help to minimize resistance. An amplified reflection for this statement might be 'There is absolutely no way that you could find time in your day to exercise.' Reflective statements can test a hypothesis or elicit both sides of the ambivalence. These reflective listening skills can be a guiding directing approach that can assist the client in utilizing inner wisdom in moving through ambivalence.

It is my hope that this brief introduction to motivational interviewing has inspired you to find out more about this 'way of being.' The spirit of MI could be exactly what your health promotion program is missing. Engage and empower your clients on their journey to a healthier lifestyle!

To learn more about Motivational Interviewing, please see the references and resources listed below.

Journal Articles

1. Emmons, K, Rollnick, S (2001). Motivational Interviewing in Health Care Settings Opportunities and Limitations. Am J Prev Med, 20(1), 68-74.
2. Gance-Clevelend, B (2007). Motivational Interviewing:Improving Patient Education. J Pediatr Health Care, 21, 81-88.
3. Knight, KM, McGowan, L., Dickens, C., Bundy, C (2006). A systematic review of motivational interviewing in physical health care settings. British Journal of Health Psychology, 11, 319-332.
4. Resnicow, DiIorio, Soet, Borrelli, Hecht (2002) Motivational Interviewing in Health Promotion: It Sounds Like Something Is Changing. Health Psychology, 21(5), 444-451
5. Resnicow, K, Davis, R, Rollnick, S (2006). Motivational Interviewing for Pediatric Obesity: Conceptual Issues and Evidence Review. J Am Diet Assoc, 106, 2024-2033.
6. Richardson, CR, Schwenk, TL (2007). Helping Sedentary Patients Become More Active:A Practical Guide for the Primary Care Physician. JCOM 14(3), 1-11.

Books

1. Miller, WR, Rollnick, S, Conforti, K (2002). Motivational Interviewing: Preparing People for Change. Guilford Publications, Inc: New York, NY.
2. Miller, WR, Butler, CC (2007). Motivational Interviewing in Health Care: Helping Patients Change Behavior. Guilford Publications: New York, NY.

Website:

1. http://www.motivationalinterview.org

If your organization would like to learn how to effectively utilize the spirit of Motivational Interviewing in your health promotion activities for people with disabilities please contact:

• Charles H. Bombardier, PhD Professor
  Department of Rehabilitation Medicine
  University of Washington School of Medicine
  Box 359740
  Harborview Medical Center
  325 9th Avenue
  Seattle, WA 98104-2499
  206-744-3665 (Voice)
  206-744-8580 (FAX)
  chb@u.washington.edu (E-mail)

---

For comments and feedback, please feel free to contact Amy Rauworth at amyr@lakeshore.org.