Advanced Counseling Skills that Motivate and Create Change – Part 2 Nina Crowley, PhD, RDN, LD
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Advanced Counseling Skills that Motivate
and Create Change – Part 2Nina Crowley, PhD, RDN, LD
Nina Crowley, PhD, RDN, LD Medical University of South Carolina
Bariatric Surgery Program
Heidi Diller, RDReShape Medical
Objectives
● Formulate counseling strategies in response to common issues ReShape patients face
● Consider using techniques borrowed from patient-centered care models: motivational interviewing, mindfulness, intuitive eating, and the empowerment approach
● Adapt counseling style to meet the needs of patients struggling to make long term behavior change for weight management
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Learn how to:
7/25/2017 Pre-Approved for 1 CPEU! Download certificate on handouts dashboard
POLLS4
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Common Dietitian Dilemmas & Approaches to Try
● I thought my patients weren’t supposed to be hungry. Why isn’t this working? — Try an Intuitive Eating Approach
● Patient is telling me they are doing everything right and they stopped losing weight. Plateau.— Try using a Mindfulness Approach
● I can’t get them to come back. They say they can lose the weight on their own. — Try using the Empowerment Approach
● Do you have curriculum I can use? They asked for meal plans, what do I give them?— Try using Motivational Interviewing Approach
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I thought my patients weren’t supposed to be hungry. Why isn’t this
working?
Intuitive Eating Principles7
Evelyn Tribole & Elyse Resch - http://www.intuitiveeating.org/10-principles-of-intuitive-eating/
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1. Reject the Diet Mentality.2. Honor your Hunger3. Make Peace with Food4. Challenge the Food Police5. Respect your Fullness6. Discover the Satisfaction Factor7. Honor Your Feelings without Using Food8. Respect your Body9. Exercise - Feel the Difference10. Honor your Health
Intuitive Eating Principles
1. Reject the diet mentality— Allowing the hope that a new/better/faster/easier “diet” (or procedure) is out there will prevent patients from being free
to re-discover eating intuitively
2. Honor your hunger— When someone is not biologically fed with adequate energy (including carbohydrates!) – they may be triggered to overeat
– excessive hunger undermines intentions to eat moderately, consciously
3. Make peace with food— The inner dialogue of “shouldn’t” and “forbidden” food leads to feeling deprived, uncontrollable cravings, and often “giving
in”, overeating, and guilt (don’t be that voice) - giving unconditional permission to eat is difficult but liberating (help them)
4. Challenge the food police— Moving away from the inner police (or outer police – you?) who says you are “good” for “good foods” and “bad” for “bad
foods” according to diet rules is critical to eating intuitively. Attribution not judgment.
5. Respect your fullness— Observe and listen for body signals to tell you that you are no longer hungry or uncomfortably full. The balloon will help
patients to learn this so that when removed, patients are used to ‘checking in’
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Intuitive Eating Principles
6. Discover the satisfaction factor— The eating experience can be pleasurable and satisfying, and often more ‘fulfilling’ foods take less to feel that
you’ve had ‘enough’. When in ‘diet mentality’, you may not question what you want – focus is on ‘should’.
7. Honor your feelings without using food— Comforting, nurturing, distracting and resolving issues without using food is difficult but worth discovering.
8. Respect your body— Acceptance of and being less critical of one’s body shape is difficult when focus is primarily on weight loss.
Don’t be the one pushing the weight loss agenda, promote body acceptance!
9. Exercise – feel the difference— Shifting focus to movement and activity and how it feels (energy vs. calorie burn) is more motivating
10. Honor your health— Think about consistency and eating well over the longer term – and focus on honoring health, taste, and
feeling well rather than perfection and weight loss in the short term
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IE Application
● Goal is not hunger avoidance, but understanding and responding to their hunger cues— Teach cues for eating and stopping and use balloon as a catalyst
● Explore reactions to different textures of foods that ‘sit’ and those that ‘slide’
● Telling patient they aren’t ”supposed” to be or do anything sets them up for more diet-rules and dysfunctional eating— What if they are hungry? This starts the start shame/blame cycle of failure all over again!
● Explore their interpretation of “head/emotional hunger” vs. “physical/stomach hunger”
● The idea of not having hunger may be attractive at first but is worrisome
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My patient is telling me they are doing everything “right” and they stopped
losing weight. They are stuck at a plateau.
Mindful Eating Principles
● Allowing yourself to become aware of the positive and nurturing opportunities that are available through food selection and preparation by respecting your own inner wisdom
● Using all your senses in choosing to eat food that is both satisfying to you and nourishing to your body
● Acknowledging responses to food (likes, dislikes or neutral) without judgment
● Becoming aware of physical hunger and satiety cues to guide your decisions to begin and end eating
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Mindful Eating: Am I Hungry?
● Part of ancient mindfulness practice — Eating with intention of caring for yourself— Eating with attention necessary for noticing/enjoying food and effects on your body
● Process of eating— Awareness of physical and emotional cues— Recognition of non-hunger triggers for eating— Learning to meet other needs in more effective ways than eating— Choosing food for both enjoyment and nourishment— Eating for optimal satisfaction and satiety— Using the fuel you’ve consumed to live the vibrant life you crave
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Michelle May - http://amihungry.com/
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Mindful Eating: Am I Hungry?
● Questions to help recognize, understand, and change decisions about eating:
— Why do I eat?— When do I feel like eating?— What do I eat?— How do I eat?— How much do I eat?— Where do I invest the fuel I eat?
● Awareness of each decision point in mindful eating cycle may help patient discover small changes that can make a difference in why, when, what, how and how much they eat, and where they invest their energy
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http://www.amihungry.com/pdf/Mindful-Eating-for-Bariatric-Surgery.pdf
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ME Application
● Explore the concept of “plateau” for them and their expectations— Is it that they are trying really hard and expecting more weight loss, linear weight loss?
● Consider non-weight based behavioral goals — What functional goals or life goals motivated them to initiate efforts for weight loss?
● Ask what “doing everything right” means to them? — Are you promoting an “adherence/compliance” model where the only option is compliance or
noncompliance, or right/wrong?● Try concepts from Acceptance and Commitment therapy (ACT is a mindfulness based
therapy) to move from avoidance/rigidity to acceptance/flexibility— Accept your reactions and be present, Choose a valued direction, Take action
● While concept is new/difficult, consider an app – “Am I Hungry? Mindful Eating Virtual Coach App”for checking in when you feel like eating, and guiding through mindful eating process
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I can’t get them to come back. They say they can lose the weight on their
own.
Empowerment Approach
● Medical/Surgical model to treat acute conditions— Provider is responsible for diagnosis, treatment, outcomes— Providers set therapeutic goals (they know best) and “do as I say” — After weight loss treatment, patients have obligation to follow directions of the provider, and
believe of ‘compliance’ outweighs impact of these recommendations on quality of life— Results of this model – 36% “noncompliance” to post-surgical treatment regime…
● Empowerment Model— Patient-centered collaborative approach tailored to match fundamental realities of care— Helping patients discover and develop the inherent capacity to be responsible for one’s own life— Recognizes that patients are in control of and responsible for daily self-management after
procedure, and success depends on the self-management plan fitting the patient’s goals, priorities, and lifestyle as well as facilitating weight loss
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Empowerment Approach
● Choices— Patients make choices each day that have greater impact on outcomes than recommendations by
health professionals
● Control— After leaving clinic/conversation, patients are in control of which recommendations they
implement and ignore
● Consequences— Consequences of decisions accrue directly to the patients, they have the right and responsibility to
management weight loss course in way that is best suited to context/culture of their lives
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Based on 3 fundamental aspects of chronic illness care
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Empowerment Approach
● Role of provider— Help patients make informed decisions to achieve their goals and overcome barriers through
education, appropriate care recommendations, expert advice, and support— Providers bring knowledge and expertise about obesity and treatment— Frustration with “getting patients to change” is less when their behavior is not your responsibility
● Role of patient— Be well informed active partners/collaborators in their own care— Expertise on their own life and what will work for them— Actively collaborating in the decision-making process makes it more likely to achieve outcomes
that are identified as important to onself
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Collaboration between equals
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EA Application
● “Behavioral experiments” as a short-term/monthly goal — Discuss self-management, psychosocial issues, and coping— Experiment eliminates ‘success’ or ‘failure’ concepts
● Patient-selected goal setting with clarity1. Define the problem2. Ascertain patient’s beliefs, thoughts and feelings that may support or
hinder efforts3. Identify long-germ goals to work towards4. Commit to making behavior changes that will help to achieve long term
goals5. Evaluate efforts and identify what was learned in the process
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EA Application
● Show that you care about patient first, weight loss second● Start sessions with how they are feeling and how they believe they are doing in reaching
their self-selected goals and caring for themselves before jumping into diet/exercise/weight● Stress importance of their role in self-management and daily decision making● Address patient’s agenda at the beginning of the session
— “We have 15 more minutes to spend today, and I want to be sure that your needs are addressed. Are there issues that you would like to discuss?”
● Remember, that in the end, they ARE doing it on their own! ● Begin the coach-client relationship acknowledging that the visit structure works for some,
not all, and that if they move to “doing it on their own” and it works, great! And if not, it is a ‘safe, judgment-free’ zone to return!
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Do you have a curriculum I can use? I’d love to base my education off
something else…Patient says they want a meal plan.
What should I give them?
Motivational Interviewing Principles
● Client resistance is a product of the environment, not an intrinsic behavior
● The patient and provider relationship should be cooperative and congenial
● MI centers around overcoming ambivalence
● The practitioner keeps options open
● Responsibility rests on the patient
● Self-efficacy is paramount
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Motivational Interviewing Approach
● MI incorporates 5 counseling techniques that help individuals address ambivalence or insecurities surrounding health choices and behaviors 1. Expressing empathy2. Developing discrepancy3. Rolling with resistance/ Avoiding argumentation4. Supporting self-efficacy
● MI assists the individual to examine his wants, fears, expectations, hopes and inconsistencies, and then how these impact or influence the problems identified
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1. Expressing Empathy
● Enter the patient’s world:— What are the patient’s concerns? — Why is change difficult? — What outcomes does the patient want to see? — What obstacles are in the way? — What is the patient’s background?
● Move beyond just understanding a patient’s unique situation to reinforcing your complete understanding
● When people feel that they are heard and understood—all their challenges, desires and fears—they will be more open to input from you on advice and wellness
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Acceptance facilitates change whereas pressuring patients to change increases resistance
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2. Developing Discrepancy
● Creating a stark picture for the patient that pits their current behavior against their present values and future goals/what is important to them
● Makes the patient more aware of the future results of their decision-making
● You cannot motivate or instill motivation in them…
● Help patients hear their own motivation
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Evoke their own reasons for and against change, while resisting coercion
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3. Rolling with Resistance/Avoid Argumentation
● Seeks an avenue to travel together to change
● Flows with resistance, moving toward closer inspection of patient's mindset
● Focus on patient’s view of problem
● Resist the ‘righting reflex’ that we have to actively try to FIX other peoples problems
● You arguing for change, assuming the expert role, criticizing, shaming, blaming, labeling or being in too much of a hurry increases resistance
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People are not resistant to change. They resist being changed.
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4. Supporting Self-efficacy
● Empower positive feedback & communicate hope ● Recognize and applaud self-efficacy when you
hear it● Patients will gain a better belief that the current
change in question is attainable ● Promote goals that the patient actually can
achieve - reinforcing ability to change and the sense of accomplishment in doing so
● Refer to past accomplishments or provide examples of other patients who have become owners of their own change
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The solutions lie within your patients
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Motivational Interviewing Micro skills
● Open ended questions force the patient to elaborate on a given thought, topic or feeling
● Affirmations reaffirm a patient’s strides toward positive behavior change instills self-efficacy
● Reflective Listening deepens levels of understanding and enhance trust between practitioner and patient
● Summarizing reiterates the recent progress, related concerns, actions, or roadblocks, gleaned from the interaction.
● *before summarizing, the practitioner should announce that a summary is coming and invite the patient to interject any feedback, including differences in perspective
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● To elicit change talk— Ask evocative questions— Ask for examples— Use extremes— Look back & forward— Explore goals— Use the position ruler— Elicit problem recognition— Elicit concern & optimism
● Once you hear it – respond! — Tell me more about that…— So given all of this, what do you think you’ll do next?— What if anything, will you do now?
31 Change talkMention and discussion of desire, ability, reason and need to change
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Putting together a change plan (SOAR)
● Setting goals—help your patients decide which goals are important to them● Sorting options—use the elicit, provide, elicit model and ask the patient to brainstorm on
ideas● Arriving at a plan—assist the patient in thinking through the steps of the plan, difficulties
they might face, how they might address these difficulties and how they will evaluate if the plan is working
● Reaffirming commitment—use the position ruler to ask the patient to rate the importance and confidence in following this plan
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● Knowledge does not equal motivation ● Nonadherence does not mean the patient does not want to change● It is the patient’s agenda, not yours! I repeat – its about them, not you!● Match the counseling technique or skill to the patient’s stage of change● It is not your responsibility to make the patient change or adhere to the plan ● Learning about intuitive and mindful eating will be valuable long term ● Ditch the rigid rules, diffuse expectations, and get to know your patients!
After this presentation, I hope you learned that:
33 Take Home Messages
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