One of my biggest interests in health and fitness is behavioral coaching. Many chronic health issues boil down to decisions people make day in and day out. Coaching is both an art and a science that can help people change their behavior and thus their health. Coaching is a science in that we can systematically examine interventions and observe the influence the intervention had on behavior.For example, if a coach enhances a client’s motivation or confidence, does that lead to changes in behavior? Coaches can observe how people act under certain circumstances and prescribe interventions based on their needs.
But coaching is also an art because the delivery of behavior change techniques often occurs in person-to-person interaction. Effective delivery relies on reflective listening to understand a client's barriers. It requires collaborative problem-solving to help motivate change and act upon plans.
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What is Motivational Interviewing?
Motivational Interviewing (MI) sits right at the intersection of art and science. It is a counseling style that aims to help individuals get ‘unstuck’ from ambivalence and increase personal motivation for change.
MI was developed by psychologists Steven Miller and William Rollnick. It is less about specific techniques and more about the fundamental spirit that underlies them. MI is a way of being with people. At its core, Motivational Interviewing (MI) is a way of being with clients.
This way of ‘being with people’ is non-confrontational. It is a collaborative, empathetic, and goal-oriented style of communication. It assumes that the client is the expert on their behavior. Effective MI helps clients discover their reasons for change by providing acceptance, compassion, and active listening. It is important to understand why a client would want to change and explore their ambivalence about change.
What Are the Principles of Motivational Interviewing?
Coaches can use the general principles of MI to help their clients achieve sustainable change. These principles include (1) expressing empathy through reflective listening (2) helping clients identify discrepancies between their values or goals and their behavior (3) support self-efficacy, and (4) learning to roll with resistance.
Coaches can express empathy by using reflective listening that clarifies and expresses an understanding of a client's own experiences, goals, and personal meaning of those goals. Empathy is expressed without imposing a view or agenda. With each client statement, the coach should be working to try to understand the underlying meaning behind their words.
Discrepancies drive behavior through a feedback loop. Without a discrepancy, there is no motivation. People take in information about their current self and their current behaviors. If a discrepancy is perceived between ideal and current health or behavioral status, action is taken to reduce this discrepancy.
For example, if a person has an ideal weight of 180 pounds and currently weighs 200 pounds a discrepancy exists. If a person has consumed alcohol every night for the last week when they normally do not drink, the discrepancy would motivate them to cut back. In MI, coaches help to increase perceived discrepancy to drive motivated action.
To increase and make use of discrepancies coaches can use several strategies. Coaches can help clients develop a greater discrepancy by listening. Try to understand their goals and on a deeper level. Seek to understand why their goals are important. Ask them, without judgment, how some of their problematic behaviors align with their goals and values.
Self-efficacy is a person’s confidence that they can successfully execute behaviors required to produce outcomes. Self-efficacy can be influenced in four ways: through performance accomplishments, the success of similar others (vicarious experience), verbal persuasion, and through emotions such as stress (physiological states). The more challenging a behavior, the more confidence becomes important.
For example, going for a twenty-minute walk once per week is less challenging than running for twenty minutes three times per week. Coaches can foster confidence by helping clients find appropriate challenges. One’s that are attainable but not overwhelming. Coaches should also express their own belief in the client’s success. This can be done with affirmations or positive statement about the client’s character that acknowledges their efforts.
Arguing with clients over their behaviors puts them in a position to become defensive and make statements that would sustain their unhealthy behaviors. Coaches should avoid arguments at all costs. With MI, coaches do not fight against resistance, rather they flow with it. Resistance should be seen as an opportunity to explore with more reflective listening and open-ended questions.
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What Does OARS Stand For?
In motivational interviewing, OARS stands for
- Open-ended questions
- Reflective listening
Open Ended Questions
Closed-ended questions are those that can be answered with a yes or no.
Open-ended questions require more complex answers. These kinds of questions invite discussion and can be used to explore a client’s thoughts and feelings. For example, rather than asking a question such as “do you want to eat more vegetables”, a coach may say “how would you go about making this change?”.
Affirmations show appreciation for a client's strength. They are positive statements about character strengths. These statements can enhance a client’s confidence.
Reflective listening is a technique that attempts to understand the meaning behind a client’s words. When people speak, they encode their thoughts (often imperfectly) into words. With reflective listening, the coach tries to decode the meaning behind the words. Reflective statements are powerful because they demonstrate active listening.
Summarizing is a series of reflections. Summaries draw the important parts of conversations together. This gives the client a chance to clarify what was said or how what they said was interpreted.
Motivational Interviewing Examples and Sample Questions
A coach can explore why a goal is important to a client (value exploration) by using reflections. Here is an overview of an example I had with a new client which I reference in the NASM’s nutrition coaching certification. In this situation, I wanted to discover why the client's goal mattered.
COACH: Thanks for signing up to work with me. I looked at some of your goals from your application, but I’d like to hear from you. Could you tell me more about what you would like to get out of working with me?
CLIENT: My big goal right now is to lose 15 pounds. Once I get there, I would like to make another goal of getting to 30.
COACH: Great, thanks for sharing that. We can get into some specifics of what you think will work best for you to achieve that goal. But before we do that, I want to understand more about why this is an important goal for you to achieve. So, if it is okay with you, we’ll just go through a series of questions. Does that work for you?
COACH: Let’s start with why this is an important goal to you. Why is losing 15 pounds important?
CLIENT: It’s important to me for health reasons and confidence reasons.
COACH: Reaching your goal will improve how you feel both mentally and physically.
CLIENT: Exactly, I’ve injured my shoulder before, so it is important for me to not worry about hurting it. I also want to feel comfortable in my skin. I want to be happy with how I look rather than miserable. I want to rebuild my self-worth.
COACH: This sounds like if you achieved this goal, it would have a big impact on other areas of your life. Can you tell me a little more about why it is important for you to feel confident? à open-ended question
CLIENT: Low confidence is affecting other areas of my life. I want to feel like a normal 26-year-old who doesn’t compare themselves to their friends. I want to feel comfortable when I’m dating rather than feeling self-conscious.
COACH: Would it be safe to say that another goal for you is also to build up your confidence? Feeling comfortable in your skin is a priority.
CLIENT: Yes, I think doing these training sessions can help me get to a place where I love to exercise. I want to learn how to do it correctly, so I don’t get anxious when I go to the gym. I think this could help me gain self-confidence to be stronger and healthier overall.
What Are the Benefits of Motivational Interviewing?
Challenges with health behavior change can be broken down in two ways, the first is an issue with adoption or starting. This can be thought of as a motivation issue. The second issue is maintenance or staying consistent with the behavior which can still boil down to a motivational issue. MI is a technique that can help clients voice and understand their motives for change.
It can also help clients understand their values and build intrinsic motivation which can help with maintenance. By improving reflective listening and ask thought-provoking open-ended questions, coaches can help clients resolve ambivalence, earn their trust, and collaboratively help them design sustainable solutions to achieve optimal health.