Cassandra Padgett is an ACE Certified Health Coach and a PN1 Nutrition Coach. She has experience coaching in corporate wellness and health insurance settings and is currently a clinical health coach and senior health educator for a childhood obesity prevention program in San Diego, Calif. Cassandra is passionate about helping families optimize health through simple nutrition changes and mindful eating. She holds a master’s degree in health promotion and education from the University of Utah, and a bachelor’s degree in public health from Brigham Young University.
Revisiting MI: How to Apply Motivational Interviewing Techniques for Better Client Results
Motivational interviewing (MI) is a client-centered approach to behavior change and one of the most effective coaching tools for partnering with clients to improve their outcomes and results.
According to William Miller and Stephen Rollnick, who began studying and applying MI to health behavior change nearly four decades ago, “Motivational interviewing is a guiding style of communication that sits between a following style of communication (good listening, not giving information, letting you figure things out on your own) and a directing style (giving information, instruction and advice). A skillful guide is a good listener and also offers expertise where needed” (Miller and Rollnick, 2013). The “spirit of MI” is rooted in connection and collaboration between the client and coach.
Proven effective by decades of research, MI has been studied in a wide range of areas of health behavior change, including smoking cessation, medication adherence and promoting oral health habits among adolescents.
As a health and exercise professional, MI requires you to follow the client’s lead as the expert in their own life. No matter how much education or training you have, the client will not be successful for the long term unless they feel some ownership over the process. It can be tempting to go back to the medical model of care, wherein the coach is the expert telling the client what to do. However, in most cases, this will not create long-lasting change. MI allows you to discover the client’s underlying motivations, hesitancies and thought patterns, which increases the chances that they will have better outcomes in both the short and long term.
The Four Key Skills of Motivational Interviewing
Motivational interviewing is made up of four key skills: asking open-ended questions, affirming, reflecting and summarizing. These skills are commonly referred to as OARS (Miller and Rollnick, 2013).
Using open-ended questions allows you to draw out pertinent information from the client while providing a point of connection and an opportunity to facilitate change talk. Phrases such as, “Tell me more about ______________,” or asking the client to get specific about why a goal is important to them can help create space for the client to open up, while also creating a connection between you and your client. Check out the sidebar for more examples of open-ended questions you can use with clients.
Open-ended questions to use while coaching:
- Tell me more about ___________________.
- What has your experience been with your (nutrition/workouts/etc.) this week?
- What specifically does health look like to you?
- How will you know when you’ve achieved that goal?
- What would it feel like to reach these goals?
- What do you think is required to achieve the goal you mentioned? How is that different from what you’re doing now?
- What obstacles are standing in your way?
- What will happen if you don’t make this change?
- Why is this change important to you?
- What’s one way you can hold yourself accountable over the next two weeks?
- What are you doing to make [insert habit] part of your routine?
- What are specific ways you can incorporate more [exercise, vegetables, water, etc.] into your routine this week?
- How can I help you be successful?
- What questions do you have for me?
Affirming involves recognizing the client’s strengths, efforts, resources, perhaps their past and current successes, as well as noticing their commitment to showing up (even if you don’t perceive them to be making progress or following through on their goals) to accentuate the positive. The purpose of affirming the client is to help them identify their strengths and gain confidence—not as a result of your praising them, but from helping them understand their own capabilities.
Sample affirmation statement: “Wow, you’ve shown up to every session for six weeks now!”
Reflecting or reflective listening refers to hearing what a client says and then making informed guesses about what you think the client means. Reflections require careful, active listening and includes making a statement about the thoughts and feelings the client is expressing and then allowing the client to think about their own words and to agree or disagree. This can be powerful in helping the client move toward change talk or making a case for wanting to change.
Sample reflection statement: “I heard you say that it’s been challenging for you to make it to the gym right now due to your schedule and you’ve made it to four out of five sessions.” From there, the client can agree or disagree, and the conversation can continue.
Briefly summarizing or recapping the key points of the conversation can help to make sure you and your client are on the same page. Summaries can also be used to connect links between present material and topics discussed before, transition from one task to another, pull together a person’s motivations, intentions, and next steps, and provide an opportunity for the client to fill in anything that was missed.
Sample summarizing statement: “Working out was really challenging for you this week due to a busy schedule, but you think it’s important because you’re noticing progress. You would like to keep three workouts as your goal this week. Did I understand that right?”
The Elicit-Provide-Elicit Approach to Offering Advice
Miller and Rollnick refer to an approach called elicit-provide-elicit, which involves first asking for a client’s permission before sharing or offering advice, then providing the information, and finally asking if they have questions or need further clarity. It’s important that you provide information in small chunks rather than long tangents or lectures.
Here’s an example of what this elicit-provide-elicit approach might look like when a client mentions not meeting their protein goal during the week:
Coach (elicit): “I’m hearing you say meeting your protein goal has been challenging. Would it be O.K. if we talked about various protein sources you could possibly include this week?”
Client: “Yes, that would be helpful.”
Coach (provide): I have a handout for you, so you don’t need to worry about remembering all this, but a few great sources of protein include eggs or egg whites, meat, Greek yogurt or cottage cheese, as well as plant-based sources like lentils, chickpeas and soybeans. Protein powders or shakes can also be helpful. Do you eat any of these foods already?
Client: Yes, I like Greek yogurt, steak and soybeans.
Coach (elicit): Now tell me, what ideas do you have for incorporating more protein in your diet this week? Would it be O.K. if I gave you this protein handout?
MI and Noncompliant Clients
MI can be beneficial during all sessions, but it’s especially helpful when working with a client who you may perceive to be ignoring your advice or not following through on their plan. Miller and Rollnick refer to this as ambivalence. The client wants to make a change (which you know because they have set goals and are coming to sessions) but feels hesitant and possibly isn’t quite ready to take action.
The collaborative process requires letting go of any judgement or preconceived ideas about how things “should” be done and allows the client to be who they are and reinforces that their journey is their own. While you may be tempted to judge a noncompliant client, it's necessary to attend every session with compassion, a willingness to connect and a reservoir of empathy for the client’s unique situation. This enables you to actively listen and use OARS to connect, move forward and be led by the client.
The client could have several reasons for not following through, and MI can help identify what the client is willing and able to do, as well as any underlying motivation or desire to change. Using MI allows a client to “talk themself into” changing, versus the coach forcing or convincing them to make a change.
Michele is a 35-year-old working mom with three young kids. She has a history of emotional eating, and almost every night she eats ice cream, cookies and various sugary foods after her kids go to bed. She has noted an uptick in emotional eating over the past several months due to added stress, and believes this habit is the cause of her recent weight gain.
During her first session, she indicated that she wanted to start by slowly breaking this habit and begin to reduce the number of days per week she ate sugary snacks as well as the quantity she was eating. She frequently felt sick to her stomach after snacking at night, and noticed it was also impacting her ability to fall asleep.
After multiple sessions, despite working on planning ahead for nighttime snacking, and multiple emotional eating strategies, the client continues to eat ice cream every night. Her coach begins to feel annoyed and judgmental, which causes the client to feel withdrawn and judged. The coach decides to change their approach and shows up to the next session ready to listen after yet another food journal indicates ice cream every night.
Coach: “I wanted to tell you I really appreciate you being open to sharing your food journals this week.”
Client: “I almost didn’t send them to you because I felt so embarrassed.”
Coach: “If you’re open to it, could you tell me more about that?” (open-ended question)
Client: “I feel embarrassed about the ice cream I eat every night. I didn’t meet my goal of only having ice cream on three days this week—I can’t believe I ate ice cream every night! But I have noticed that my portions have really gone down. I no longer feel sick afterward. It’s just that I look forward to my ice cream after a long day.
Coach: You’re making progress toward your goal of eating less sweets at night. How does that feel? (affirm)
Client: Well, I was feeling down on myself for continuing to eat ice cream at night, but I guess I am eating less. I’m noticing a container of ice cream that used to last three days is lasting longer than a week. My portions have been smaller. I’m able to be satisfied with a lot less ice cream, and I notice I enjoy it more when I’m able to slow down.
Coach: You were feeling upset because you are continuing to eat ice cream every night, but having a smaller portion is working for you because you’ve been using some of the mindful eating strategies we’ve talked about and you are no longer eating until you feel sick. (reflecting)
Client: That’s correct. I still would like to get to the point of only having ice cream a couple nights per week, but I guess I’m getting closer.
Coach: Breaking the habit of eating ice cream every night is still important to you, you have made progress regarding your portion sizes and feel like you are getting closer to your goal, and you intend to only eat ice cream on a few nights per week. How would you like to move forward? (summarizing)
By approaching the topic with compassion rather than judgement, the coach and client were able to connect, which allowed the client to share that while the food journals may look the same, she’s decreased her portions and is able to use her fullness cues to stop before she’s feeling sick.
Had the coach come to the meeting saying something like: “I see that you didn’t meet your goal of eating ice cream only three times this week” or something similar, it wouldn’t have allowed space for the conversation to progress. In fact, it may have caused things to stay exactly the same or worsened due to the shame or embarrassment the client may have felt.
How to Practice Motivational Interviewing
- Write down two or three open-ended questions you can use during an upcoming session and two or three you can use for check-ins between sessions (via text or email).
- Come up with three affirmations (not praise!) for current clients based on their recent wins. Use at least one when you’re meeting with them.
- Role play with another coach (or a partner, friend, etc.). This can be with a real or fake scenario to practice using OARS. Don’t be afraid to keep notes while practicing but remember that active listening involves no distractions, so keep the notes to a minimum while coaching clients.
Motivational interviewing is arguably the most important tool in coaching, and should be thought of as a “practice” versus a learned skill. Just as you take continuing education to continually learn and improve, improving MI skills means becoming a better coach. The good news is that you can practice the basics any time. While MI should be reserved for coaching conversations, asking great questions, allowing space for silence, and practicing active listening can be practiced in any conversation you have with others.
Miller, W. and Rollnick, S. (2013). Motivational Interviewing: Helping People Change. New York, N.Y.: Guilford Press.