Reshaping the Obesity Discussion

Motivation Interviewing Technique Offers New Approach to Reducing Resistance to Change

April 16, 2013

By Cindy Hutter

Robert Schwartz, MD
Robert Schwartz, MD, shares how motivational interviewing techniques are helping to reshape the obesity discussion.
A counseling approach first used to treat people with alcoholism and substance abuse is now finding practical application in helping to combat obesity.

Motivational interviewing is a style of communication for helping someone to change his or her behaviors by exploring and resolving their ambivalence to change. At the heart of motivational interviewing is a patient-centered, guiding approach to conversations, which moves away from the traditional directing style. Think “What things are not so good about drinking sodas?” or “What might happen if you don’t change your soda intake?” instead of “You should eliminate all sodas from your diet.”

NICHQ recently sat down with Robert Schwartz, MD, a Professor Emeritus of Pediatrics at Wake Forest School of Medicine in North Carolina and a faculty advisor to NICHQ’s Mass in Motion Kids project, to learn more about how motivational interviewing is offering a new tool for healthcare providers in addressing obesity within their communities.

What is different about motivational interviewing compared to traditional conversations about healthy living?
The conversation is patient-centered, not doctor-centered. That means we listen to our patients more than we usually do. We need to hear how their problem, whatever it is, affects their daily lives. We want to use a style where we facilitate and guide the discussion. We want to enhance motivation to change and encourage patients to take responsibility for their behavior. When we have an unmotivated person, it could be because of unresolved ambivalence. Motivational interviewing helps people get unstuck from their ambivalence.

What are the main components of motivational interviewing?
There are four guiding principles of motivation interviewing.
  • The first is to resist arguing and persuasion. When you are trying to make an argument for change and see that your client is being resistant, you need to back off. Do not counterpunch. That is a red light. Instead, you want to use a tool called reflective listening.
  • The second thing is to understand your patient’s motivations, their values and what is important to them. You need to stand in their shoes and see things from their point of view.
  • Third, you want to listen and you want to listen with empathy.
  • Lastly, you want to empower your patient. A patient’s belief in their ability to change increases their chance of success.

For healthy living conversations, is it best to have these talks with just parents, just children or together?
Parents must be involved. Teenagers do not do the family grocery shopping and make family decisions. The age and maturity of the child will be the deciding factor in whether to include the child in the process. This usually occurs at about 12 years of age, but is an individual factor.

A lot of people, especially children, provide brief responses in difficult conversations. How do you get patients to open up?
Use open-ended questions so a patient can’t answer with a “yes” or “no.” For example, instead of asking “Is school going well?,” ask “What’s going on at school?” Using phrases such as “are you,” or “tell me” or “what are your thoughts about,” will draw out information from your patient.

The open-ended questions start the conversation, but reflective listening – the core of motivational interviewing – keeps the conversation going. Restate and rephrase what the patient tells you. As you get more comfortable with the technique, you can reflect the emotion the patient is sharing and build a rapport that keeps patients talking. For example, in the beginning, you might say “It sounds like you are having trouble in gym class” in reaction to what you are hearing. Or you can reflect back some meaning and say “It’s been difficult for you in gym class because of your small size...”

What are some tips for reducing patients’ feelings of being threatened or judged during these conversations?
Sometimes it helps to talk about the pros and cons of making a change. If we use dining out as an example, we would ask: “Could you tell me some things you like about dining out?” “What things are not so healthy about dining out?” “What might happen if you don’t change your frequency of dining out?” “How would changing dining out habits affect your family?”

It’s important to remember that change doesn’t happen in the office; change takes place at home. You want to get your patient or parent thinking about making change without backing them into a corner.

How do you know if someone is ready to change?

People are not motivated to change until they are ready, willing and able. You can ask someone, “On a scale of zero to 10, how important is it for you to change?,” and using that same scale, “Assuming you wanted to change, how confident are you that you can do it?” Based on the number they choose, you can probe lower and higher, asking questions such as, “Why did you not choose a lower number,” which allows the patient to make the argument for change, or “ What would it take to get you to a higher number?,” which identifies barriers to change.

Some people are not ready to change. If that is the case, you can acknowledge that with them and ask if it is OK to discuss the topic at the next visit. For those who are ready, motivational interviewing empowers patients to ultimately make the argument for change and identify obstacles themselves. This patient-centered focus is essential for lasting change.