Motivational Interviewing

An Interview with Eileen Stellefson, MPH, RD, FADA

(MI) is a counseling technique that can be used to help clients recognize problems and then make informed decisions about whether or not they want to work on change. 1

The goal of MI is to help the client identify reasons to work toward change. To meet this goal, care providers are encouraged to adopt a curious and empathic stance, at the same time highlighting options for the client and emphasizing that the client is ultimately responsible for change.

MI stems from Prochaska and DiClemente’s theory about how people change, namely the Transtheorectical Model of Change.2 According to this model, individuals progress through five “stages of change” and use different cognitive and behavioral “processes of change” when attempting to alter problem behaviors. The five stages of change are: 1) pre-contemplation (being unaware of a problem, or being aware of it but not wanting to change); 2) contemplation (seriously thinking about change); 3) preparation (inconsistently taking action); 4) action (consistently working on change); and 5) maintenance (working on relapse prevention). The idea that motivation fluctuates as a function of an exchange between two (or more) individuals led to the development of MI.1

MI and stages of change have been applied to many different populations, particularly patients with addictive behaviors. Recently, Eileen Stellefson emphasized the use of this counseling style with eating disorders in her manual, Winning the War Within: Nutrition Therapy for Clients with Anorexia and Bulimia Nervosa.

This past summer I had the opportunity to interview Ms. Stellefson. I was very interested in learning more about her experience with MI and her understanding of the stages of change construct as it is applied to nutrition counseling of clients with eating disorders.

Why Use MI as a Counseling Technique?

LW: Why do you recommend that nutrition professionals use MI as a counseling technique in their clinical practice with eating disordered clients?

ES: Motivational interviewing is essential when working with clients with eating disorders because the nature of the disease keeps them in conflict between getting better and maintaining their eating disorder. When I see a client with a cholesterol problem who says, “I just don’t care. I don’t want to get help,” I tell him to come back when he is ready to change. You can’t do that with the client with an eating disorder. Conflict is to be expected.

Determining Readiness to Change

LW: How do you assess a client’s motivation or readiness to change her present relationship with food and her eating disorder? How do you determine the stage of change the client is experiencing?

ES: I use open-ended questions and reflective listening skills to assess the client’s current motivation and readiness to change, beginning at the initial nutritional assessment. This continues throughout the counseling process. If there is any conflict at all, the client is at least in the contemplation stage. Clients in the Pre-contemplation stage of their eating disorder most likely don’t believe they have a problem. Although they may express frustration about their preoccupation with food and weight or shame about their eating behaviors, clients are not even thinking about changing. Attempts to persuade the client to eat will usually backfire.

In the Contemplation stage, the client is more willing to consider the problems her eating disorder creates and the possibility of changing some eating behaviors. At this stage, clients often have an equal balance of reasons for and against changing their behavior. In the Preparation stage, the client has made the decision to change and is in the process of taking steps to get ready to change her eating behavior. Although the client has made a commitment to change eating behavior in the Action stage, it does not mean change will automatically occur. In the Maintenance/Relapse stage the client has been making successful changes to her eating behavior.

LW: What nutrition counseling strategies do you believe are appropriate for eating disordered clients at each stage of change?

ES: The most appropriate nutrition counseling strategies in the Pre-contemplation stage include: establishing rapport with the client and creating a supportive environment; and assessing the client’s motivation, nutrition knowledge, beliefs, thoughts, fears, and physical and nutritional status. The most important activity to do with clients at this stage is to explore the costs and benefits of changing their eating disorder behaviors.

In the Contemplation stage, the nutrition professional can help the client by prioritizing and discussing eating behaviors to change; identifying barriers and exploring coping strategies; discussing food records; identifying the client’s support system; and reviewing what the client should expect physically and psychologically as she changes her eating behavior. Supporting the client to discontinue or reduce the frequency of purging, or viewing herself in mirrors, or weighing herself are essential nutrition counseling strategies in the Preparation stage. This stage is a good time to begin using cognitive-behavioral exercises with clients.

In the Action stage, the nutrition professional can reinforce the client’s self-confidence and encourage more movement toward healthy eating. Teaching the client behavioral strategies and helping her to increase her sense of self-efficacy is very important at this stage. Although the number of nutrition counseling sessions may decrease during the Maintenance/Relapse stage, the nutrition professional should reinforce continued use of the client’s coping strategies for ongoing success.

Discussing “what if…” scenarios with clients allows the dietitian to assess problem- solving skills. Care providers need to be concerned about the possibility of relapse at this stage. If the client does experience relapse, the dietitian can help by: exploring her thoughts, fears, and beliefs; providing her with the nutrition information/education; giving her feedback; and responding with empathy.

Reverting to an Earlier Stage of Change

LW: In your experience, have you seen clients revert back to an earlier stage of change (i.e., Is the actual manner of change a simple linear progression through the stages?)? If so, why do you think this occurs?

ES: Clients almost always revert to an earlier stage of change. When this happens, I wonder what else is going on in the client’s life (e.g., a stressor or a memory, etc.). In my nutrition counseling session, I might say, “For the last two months you were eating what you knew was the right amount and now you’re back to eating less than 1000 Calories a day. It makes me wonder if something else is going on that is causing you to “need” your eating disorder to cope.” I also ask the client to explore this with her therapist. In addition, I go back to my notes (it is always good to have the client write down the reasons she wants to eat healthier, and to keep a copy). I remind the client of what she/he told me were her/his reasons for changing and challenge the client on what’s different now.

Working with Medically Unstable Clients

LW: How can the nutrition professional use the stages of change model for the client who is medically unstable, requires immediate renourishment, and is in denial of the severity of her illness?

ES: When a client is medically unstable, I use very hard and fast statements and do not focus on long-term counseling strategies. For example, a common statement is “FOOD IS MEDICINE.” Period. Usually, when clients are unstable they are not thinking rationally, and it is more frustrating than productive to spend too much time assisting the client in processing information.

LW: I have noticed that a client’s readiness to change can vary depending on the eating disorder behavior. I have observed that a client may be in the “action” phase for wanting to change her binge-eating behavior but be in the “precontemplation”phase for motivation to address her restrictive eating pattern. Do you have any insight into this observation?

ES: You are absolutely correct. Often, the client wants to stop bingeing but still wants to be thin and restrictive. She/he may even say, “I want to be healthy but weigh 90 pounds.” I often talk to clients about how “incompatible” it is to be thin and healthy. I also talk about how difficult it is to stop binge eating if they are being restrictive. I use the deprivation/binge cycle example to help them see that restricting leads to binge eating. I often present this concept by asking questions, not just stating the concept (e.g., “How do you think your body would react to so few Calories?” They may say, “I might get hungry, but that’s okay.” Then I would ask, “From what we have talked about, what are the usual consequences when the body gets too hungry?”

— Linda M. Watts, MA, RD

(Note: Eileen Stellefson, MPH, RD, FADA, has been working in the field of obesity and eating disorders since 1981. Currently Eileen is a nutrition consultant and counsels clients with eating disorders in a small private practice. Ms. Stellefson’s manual is published by Helm Publishing and is available from Gürze Books: 800/756-7533 or www.bulimia.com.)