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Motivating Patients & Lifestyle Change

MODULE 1

MOTIVATING PATIENTS TO LOSE WEIGHT

ContentsMotivating Patients to Lose Weight........................................................................................................3

Introduction............................................................................................................................................. 4

Think Ahead: Motivating Patients ......................................................................................................5

Motivational Interviewing Overview........................................................................................................6

Poll: On average, for patients with weight problems, I devote __minutes per visit to motivating them to lose weight............................................................................................................................ 7

Motivational Interviewing Steps..........................................................................................................7

Patient-Centered Approach.................................................................................................................... 7

Patient-Centered Examples 8

Case #1: Ms. Campbell.......................................................................................................................... 9

Quiz: Talking About Weight..............................................................................................................10

Empathy and Affirmations.................................................................................................................11

Normalizing and Reassurance.........................................................................................................12

Open-Ended Questions....................................................................................................................12

Determine Readiness for Change....................................................................................................13

Using Readiness Rating...................................................................................................................14

Quiz: Eliciting Thoughts, Feelings ...................................................................................................15

Reflective Listening.......................................................................................................................... 15

Reflective Listening Tips.................................................................................................................. 16

Tailoring Approach by Stage of Change...........................................................................................17

More Reflective Listening.................................................................................................................17

Ms. Campbell: Case Skills Review.......................................................................................................18

Quiz: Motivational Skills...................................................................................................................18

Case #2: Mr. Murphy............................................................................................................................ 20

Engaging the Patient........................................................................................................................20

Quiz: Patient Awareness.................................................................................................................. 21

of 40 June 14, 2018 Update - Motivating Patients to Lose Weightwww.obesity.ClinicalEncounters.com


Building Confidence......................................................................................................................... 22

Elicit Motivational Statements..........................................................................................................23

Quiz: Eliciting Motivation.................................................................................................................. 24

Working With Ambivalence..............................................................................................................24

Quiz: Resolving Ambivalence...........................................................................................................25

Case: Working With Ambivalence....................................................................................................26

Mr. Murphy: Skills Review................................................................................................................26

Case #3: Mr. Harris............................................................................................................................... 27

Mr. Harris' Weight History.................................................................................................................27

Understanding the Patient's View....................................................................................................28

Quiz: Responding With Empathy.....................................................................................................29

Avoiding Resistance......................................................................................................................... 30

De-Escalating Resistance................................................................................................................30

Rolling With Resistance...................................................................................................................31

Quiz: Putting It Altogether 32

Discord............................................................................................................................................. 33

Lack of Motivation............................................................................................................................ 34

Mr. Harris: Case Skills Review.........................................................................................................34

Video: Motivational Interviewing - Managing Patient Resistance....................................................35

Applications Case: Ms. Benson............................................................................................................35

Quiz: Engaging and Focusing..........................................................................................................35

Quiz: Exploring Personal Barriers....................................................................................................36

Readiness, Motivation, Confidence..................................................................................................37

Assessing Motivation and Confidence.............................................................................................37

Quiz: Eliciting Ideas, Feelings..........................................................................................................38

Quiz: Expressing Empathy................................................................................................................... 39

Reflective Listening.......................................................................................................................... 39

Quiz: Evaluating Ambivalence..........................................................................................................40

Quiz: Plan For Change.....................................................................................................................41

Personalized Plan............................................................................................................................ 41

Clinical Protocol Steps in This Module.................................................................................................41

Module Summary.................................................................................................................................. 42

Resources available through this module:............................................................................................42



References used in this module:..........................................................................................................43

Module 1

MOTIVATING PATIENTS TO LOSE WEIGHT

Goal:To prepare the learner to effectively motivate patients who need to lose weight to participate in their weight-loss management programs.

After completing this module participants will be able to:• Follow the basic steps of motivational interviewing when counseling adult patients on weight

loss in primary care.

• Apply motivational interviewing techniques when counseling adult patients on weight loss in primary care.

• Tailor counseling of adult patients on weight loss in primary care to meet individual needs.

• Respond effectively to common challenges that are faced when trying to motivate primary carepatients to lose weight.

Professional Practice GapsEvidence-based guidelines recommend that providers use motivational interviewing techniques as a tool for encouraging behavior change when managing and preventing obesity in adults (Fitch et al., 2013). Studies suggest that training in motivational interviewing skills will benefit physicians in helpingtheir patients lose weight (Pollak et al., 2007). Use of motivational interviewing by physicians with obese patients was associated with a reduction in body mass, body weight, BMI (Armstrong et al., 2011), and positive intentions and behavioral changes, such as motivation to lose weight (Jay et al. 2009).

Despite these recommendations and findings, primary care physicians do not consistently counsel or advise patients who are overweight or obese (Simkin-Silverman et al., 2008; Smith et al., 2011). In fact, the majority of obese patients are not even told that they are overweight or obese by a physician(STOP, 2010; Bardia et al., 2007).

In our needs analysis survey (N=25), 96% of providers felt they needed the training to counsel patients on weight control based on best practice recommendations. Only 35% of providers acknowledged using motivational interviewing techniques with overweight or obese patients, while 92% of providers acknowledged a need for additional training using counseling or motivational interviewing (Tanner, 2011).



INTRODUCTIONUSING MOTIVATIONAL INTERVIEWING TO PROMOTE WEIGHT LOSS Motivational interviewing is a patient-centered counseling style, originally developed for use in substance use counseling. It is often effective when an individual is being guided to make a behavior change to improve health, including achieving and maintaining a healthy weight (DiLillo & West, 2011). Basic steps from this technique can be integrated into a primary care visit (Rahm et al., 2014).

Motivational interviewing techniques support the development of rapport, which is important when talking about the topic of weight. It is a sensitive subject for many people, both patients, and physicians. Motivational Interviewing also helps healthcare providers facilitate a patient in developing the motivation to lose weight and a plan with concrete steps to take.

Meet the Patients:

We will follow the stories of these patients in order to illustrate how to approach the 4 steps of Motivational Interviewing (M.I.) and use clinical skills effective in each step.

MS. CAMPBELL Presenting for a diabetes check-up, Ms. Campbell has not lost any weight despite receiving dietary and exercise recommendations to support weight loss many times. How can she be motivated?

MR. HARRIS Present for a follow-up on weight-related comorbidities. He is resistant to trying to diet after many failed attempts. How can you best respond to his resistance?

Mr. Murphy In for a physical exam. His BMI is in the obesity range, but he thinks he's "just a few pounds up." How can you raise his awareness without offending him?

MS. BENSON Obesity-related infertility. She lists several personal barriers to weight loss. How can you help her get past these barriers?

THINK AHEAD: MOTIVATING PATIENTS

Think Ahead: Elma Taylor seems resistant to talking about a weight-loss plan. You have made attempts, but she either changes the subject or describes reasons weight-loss attempts would not



work. You have tried brainstorming ideas to get around these barriers and suggesting small steps shecould take but to no avail. Which of the following techniques might best break through her resistance after she says in response to your latest suggestion, "That won't work for me."

Choose one

1. "I get frustrated from making suggestions when you reject all of them." • Feedback: • Incorrect. This topic is discussed on De-Escalating Resistance.

2. "That may be. It may not work for you." • Feedback: • Correct. This topic is discussed on De-Escalating Resistance.

3. "It seems like you don't really want to lose weight. Do you?" • Feedback: • Incorrect. This topic is discussed on De-Escalating Resistance.

4. "It has worked for countless other patients of mine." • Feedback: • Incorrect. This topic is discussed on De-Escalating Resistance.

MOTIVATIONAL INTERVIEWING OVERVIEW Motivational interviewing (MI) elicits behavior change through apatient-centered counseling style for addressing ambivalence aboutchange (Miller & Rollnick, 2012). Although originally developed forsubstance abuse counseling, these motivating techniques can beused in primary care to facilitate any health behavior change,including weight loss.

The Fundamental Approach

• Collaboration, evocation, and patient autonomy rather thanconfrontation, education, and authority.

• Elicit from patients their ideas and insights regarding the problematic health behavior rather than imposing ideas and insights on the patient. In the case of weight loss, it is important not to make assumptions. There are a lot of variations in patient attitudes about obesity and related behaviors.

• An attitude of partnership, acceptance, and compassion builds rapport.

(Miller & Rollnick, 2012)

FULL DEFINITION

Motivational interviewing is a collaborative, goal-oriented style of communication with particular attention to the language of change. It is designed to stimulate personal motivation for commitment to a specific goal by eliciting and exploring the person's own reasons for change within an atmosphere of acceptance and compassion" (Miller and Rollnick, 2012).



PRACTICE TIPSTo apply motivational techniques in weight management, recognize the patient's expertise on his or her own motivations to lose weight and how they can best go about it.

Motivational interviewing can make a difference even if you only spend one minute using one of the techniques described in this module. Longer interventions of 10 minutes or more are more effective, however. It is also important to keep doing motivational and supportive interventions at each appointment.

POLL: ON AVERAGE, FOR PATIENTS WITH WEIGHT PROBLEMS, I DEVOTE __MINUTES PER VISIT TO MOTIVATING THEM TO LOSE WEIGHT.

1. Less than 1 minute • 22% (31 votes)

2. 2 minutes • 22% (32 votes)



5. Greater than 10 minutes • 10% (15 votes)

Total votes: 144

MOTIVATIONAL INTERVIEWING STEPSBrief Counseling Protocol Step: Use the four steps of Motivational Interviewing to facilitate advancements in the stages of change as needed.

FOUR BASIC STEPS ARE FOLLOWED IN MOTIVATIONAL INTERVIEWING:1. Engaging – Gain the patient's trust and interest in making a change 2. Focusing – Help the patient focus on the problem 3. Eliciting – Use questions to guide the patient in stating feelings and goals 4. Planning – Facilitate the patient in establishing a plan for achieving the goals


The cases in this module illustrate how these steps are achieved. A variety of counseling skills are used to motivate patients to change behavior patterns and take actions needed to lose weight.

DID YOU KNOW?Motivational interviewing is most useful after initial screening for overweight/obesity and before making any recommendations (Rounsaville, 2002).



PATIENT-CENTERED APPROACHIn a patient-centered, motivational approach, the provider guides the patient rather than tells the patient. These non-directive approaches differ from advice-giving (directive) by healthcare professionals. Instead, the healthcare provider recognizes the expertise of the patient on his or her own motivations. The provider is only somewhat directive as they guide the patient to examine and resolve any ambivalence about the problem (Miller & Rollnick, 2012).

• Guiding: A little directing is still needed in this approach, but it takes the form of facilitation and guidance. Guide patients toward being introspective, discuss certain topics that are likely to lead toward readiness for change and resolve any ambivalence about it. Use gentle, guiding questions to direct.

• Non-Directive or Patient-Centered: Be non-directive or patient-centered by allowing patientsto come up with their own motivations, goals, and ambivalent feelings surrounding their problem behaviors. They can even develop their own plan to resolve their problems.


Does a Non-Directive Approach Work for All Patients?A directive, motivational approach may not work for every individual. Some patients may do better with more guidance. In some cultures, people may prefer to receive advice from an authority figure rather than participate in decision-making. However, the stage of acculturation varies among individuals who have moved into a culture that is new to them. Assumptions about preferences basedon ethnicity or race may not be accurate for a particular individual.

The same interventions work for all racial-ethnic groups. At the same time, differences in individual needs due to cultural, ethnic, and racial differences should be elicited from the patient and addressed(Miller & Rollnick, 2012).

PATIENT-CENTERED EXAMPLES The following table compares a more authority-centered approach with a more patient-centered approach, as is used in Motivational Interviewing. A patient-centered approach uses a skillful blend of a non-directive counseling plus guidance when needed.

Authority-Centered Patient-Centered

Doctor: "I can tell you what works for weight loss."Doctor: "I'd like to work with you to figure out what's behind your recent weight gain so that we can better figure out a plan to address it."

Doctor: "Because of your risk for developing diabetes, you need to reduce the amount of fast food you eat."

Doctor: "Reducing your fast food intake would likely reduce your risk for developing diabetes. Can we talk some about that?"

Doctor: "You need to get more exercise."Doctor: "So, you're telling me that you're unhappy with your weight, but you don't have time to exercise."

Doctor: "I want you to add 3 servings of vegetables a day and check back with me in 90

Doctor: "We have identified low vegetable intakeas a problem area in your eating habits. What's



days."one thing you can do in the next 90 days to improve your diet?"

Doctor: "You need to lose 15 pounds. I will have my assistant give you a copy of the weight-loss diet plan I want you to follow."

Doctor: "I noticed that you've been gaining weight over the past few years. Can we talk about that?"


PRACTICE TIPBe sincere: As you use these techniques, be sure to stay connected to the patient and their struggles with sincerity and respect. Patients are often very astute about when a technique is being used "on" them and resent condescension.

CASE #1: MS. CAMPBELLThe following case will show how obesity can be brought up and briefly addressed using the first several steps of motivational interviewing. This approach is comfortable and supportive of the patient.The scenario takes place during a patient encounter to evaluate several obesity-related comorbidities.

Case ScenarioPatient Name: Mary Campbell Age: 70 y/o

Height: 5'3” Weight: 193 lbs BMI: 34.2 kg/m2 Waist: 40"

BP: 125/83 Pulse: 88 Respiration: 20/min

Chief Complaint: Diabetes check-up, also experiencing ankle and knee pain

History of Present Illness: Long-standing history of type 2 diabetes. Chronic, moderate ankle and knee pain, moderately well controlled with naproxen

Medical History: Type 2 diabetes mellitus, dyslipidemia, hypertension (treated), incontinence, and osteoarthritis, especially in knees. Gained 10 lbs since the last visit 6 months ago. Insufficiently motivated to follow recommendations for weight loss. Has low confidence due to previous failed attempts at weight loss.

Medications: HCTZ (hypertension), naproxen (ankle and knee pain).

Weight History: Lost 30 lbs last year but is starting to regain it. Diet: Admits to loving sodas and junkfood too much and using them to heighten low moods.

Physical Activity Level: Insufficiently active, no exercise of moderate intensity. (Attributed by the patient to advanced age and health problems).

Weight-Related Diagnoses: E66.9 Obesity, unspecified; E65 Localized Adiposity (Central)

CASE OBJECTIVESThis case will cover the following objectives:

• Follow the basic steps of motivational interviewing when counseling adult patients on weight loss in primary care.




• Tailor counseling of adult patients on weight loss in primary care to meet individual needs. • Respond effectively to common challenges that are faced when trying to motivate primary care

patients to lose weight.

QUIZ: TALKING ABOUT WEIGHT

Ms. Campbell

Question: After building a rapport with Ms. Campbell, by asking about her family and congratulating her on good glycemic control, the provider next wants to focus the interview on her weight. Which of the following is the best choice, using a Motivational Interviewing approach, to start talking about weight with Ms. Campbell?

Choose one

1. In order for me to treat your ankle and knee pain, we have to talk about your weight. • Feedback: • This statement is very directive. It does not elicit Ms. Campbell's permission to talk

about a potentially sensitive subject and sets her up to be wrong if she does not agree to the discussion.

2. I am sorry to hear that you are still experiencing ankle and knee pain, even with medication. One thing that would be likely to help is weight loss. With your approval, I'd like to talk about your weight.

• Feedback: • Using the current health concern as the context for bringing up weight is an excellent

approach. 3. Your family cares about you a lot. Therefore, I think they would want you to improve your

health by losing weight. • Feedback: • This statement could be interpreted as the provider placing guilt on Ms. Campbell. It

imposes the provider's motivation on Ms. Campbell, rather than eliciting her motivations.

4. While your glycemic control has been good, losing weight would further improve it. • Feedback: • This statement does again acknowledge Ms. Campbell's success in achieving good

glycemic control. However, it is directive and does not elicit permission from Ms. Campbell to talk about weight, nor does it elicit her point of view.

5. I know weight is a sensitive topic, but you are obese and we have to address that issue. • Feedback: • This approach labels her as obese rather than saying, "You have a diagnosis of obesity

or your body mass is in the obese range, meaning it puts you at risk for health problems".



EMPATHY AND AFFIRMATIONSThe use of empathy and affirmations in patient interviews is important in gaining patient connection and trust. These skills are useful in several steps of the motivational technique.

EmpathyDEFINITION Expressing an understanding of things as the patient feels sees and thinks about them (Rollnick et al., 2008). Empathy is also communicated through an expression of caring in your eyes, facial expression, tone of voice, and body language.

Rationale: When people feel empathy from someone, they feel understood and validated (Rollnick etal., 2008). When patients experience empathy from a provider, they are more likely to open up to the provider and to their own experience. They will be more comfortable examining their ambivalence, forexample, about making a lifestyle change to lose weight. They will also be more open to gentle challenges from the provider.

AffirmationsDEFINITION A supportive statement made by the provider in response to what a patient has said thatverifies and acknowledges the patient's attempts to change their behavior (Miller & Rollnick, 2012).

Rationale: Failure to achieve weight loss goals can lead to a downward spiral of confidence and self-esteem accompanied by weight gain (Miller & Rollnick, 2012). A pattern of weight cycling up and down often results. This can be frustrating for both the clinician and the patient. Use of affirmations can increase patients' confidence in their ability to make healthy changes. These statements show that the provider recognizes patient strengths, efforts, and successes in making the long-term changethat is needed.

EXAMPLE OF EMPATHY AND AFFIRMATIONS Ms. Campbell responded positively to the provider's question regarding a discussion concerning her weight.

Provider: I appreciate that you are interested in talking with me about weight and your health. [Affirmation] Please tell me more about your concerns.

Ms. Campbell: I try to exercise, but when my arthritis is flaring up, I can't on some days.

Provider: I can see how this must be hard. [Expressing empathy] But you still try, which is a personalstrength. [Affirmation statement] That is something that will help you in other important ways in a weight-loss program.

When To Use These SkillsEmpathy and affirmations are especially helpful early in the Engaging step. This is when you are trying to connect with the patient and gain their trust and interest in making a change.

Connecting with the patient is also important later in the patient interview during the Eliciting step. This is when you guide the patient in stating their thoughts and feelings.



NORMALIZING AND REASSURANCE

NormalizingDEFINITION Communicating that the patient's experience or feelings are typical of many people.

Rationale: "Normalizing" helps communicate to patients that they are not alone in their experience and struggles, including feelings of ambivalence and resistance to change. Normalizing helps patients understand that many people have difficulty changing their behaviors and beliefs (Westra, 2012).

ReassuranceDEFINITION Communicating that a situation is safe or a that a positive outcome is likely.

Rationale: Reassurance that other patients have succeeded despite similar difficulties or feelings of ambivalence helps patients believe that they can succeed, thus building confidence.

EXAMPLES OF NORMALIZATION AND REASSURANCE

Ms. Campbell: Last time you told me I'd have to exercise to maintain myweight loss. I used to like to walk, but not so much anymore. It's a bit of a strugglewith my knees and when I'm feeling down.

Provider: That does sound difficult [Empathy]. I can see how being active ischallenging with your knee pain. And many people struggle with being active when they feel depressed [Normalizing]. There may be some ways to help [Reassurance]. [Proceeds with a quick depression screening (negative) and discusses the use of a cane and a physical therapy referral.]

When To Use These SkillsNormalizing and reassurance are especially helpful early in the patient interview in the Engaging step. These skills help when you are trying to connect with the patient and gain their trust and interestin making a change.

Connecting with the patient is also important later in the Eliciting step when you guide the patient in stating their thoughts and feelings.

OPEN-ENDED QUESTIONS

Use Open-Ended QuestionsDEFINITION Those that cannot be answered "yes" or "no."

Rationale: Open-ended questions require the patient to start the process of self-examination (Miller & Rollnick, 2012). They build momentum that can be used to explore issues that may lead to behavior change.

• For example — "What do you mean by that exactly?" "What ideas do you have?"

In contrast, closed-ended questions, those that lead to "yes" or "no" answers or very brief answers, do not encourage much introspection. — For example: "How many times did you eat fast food this week?" or "Did you have success with your exercise plan since I last saw you?" Closed-ended questions can be conversation stoppers.



EXAMPLE OF OPEN-ENDED QUESTIONS

[After attending to Ms. Campbell's blood pressure, dyslipidemia, and osteoarthritis, herweight is addressed:]

Provider: What do you think has contributed to your weight gain these past fewmonths? [Asking an open-ended question]

Ms. Campbell: I've been struggling to get around much with my joint pain, so I can't work in my garden anymore. I just spend a lot more time sitting around and eating...I know I shouldn't.

When to Use This SkillOpen-ended questions are especially helpful to achieve the Focusing step after you have engaged the patient and want to help the patient focus on the problem. But also use open-ended questions in all steps of Motivational Interviewing.

PRACTICE TIPSome topics that can be discussed using open-ended questions include asking the patient:

1. What they would like their weight and health to be in the future 2. To review his or her eating on a typical day 3. Asking their thoughts and feelings on diet assessment results

DETERMINE READINESS FOR CHANGEBrief Counseling Protocol Step: Assess stage of change and confidence in ability to lose weight.

Determining your patient's readiness for change is important to provide tailored treatment, which can improve chances of weight-loss success. Directly asking their readiness to change can be quick and effective:

Ask Two Questions on Readiness to Change

1. On a scale from 1 to 10, with 1 being not important at all and 10 being very important, how important is it for you now to lose weight?

2. On a scale from 1 to 10, with 1 being not at all confident and 10 being very confident, how confident are you now that you can lose weight?

(adapted from the original work of Miller & Rollnick, 1998)

Alternative Method. Use a "Readiness toChange Ruler"

Alternatively, patients can be asked to markwhere they are in the change process on theReadiness to Change Ruler, which is simply acontinuum from the left “not prepared tochange” to the right “already changing”(originally published in Miller & Rollnick, 1998).



When to Use This SkillDetermining readiness to change is helpful to achieve the Focusing step when guiding the patient to talk about the problem.

Asking about a patient's readiness to address the topic of weight might also be used to help in the next step to Elicit the patient's thoughts and feelings.

USING READINESS RATING

Example of Rating Readiness for ChangeIn the following dialogue, the provider uses the common approach for assessing readiness to change by asking her to rate it on a scale of 1 to 10.

Provider: On a scale of one to ten, how ready are you to make some changes in order towork towards losing weight? [Specific].

Ms. Campbell: Let's see....I'd say I'm at about a 5 on that right now.

A "Trick" Question Using the Readiness RatingProvider: Why didn't you choose a lower number than you chose?

Ms. Campbell: Lower? I thought you would ask why not higher. It's not lower than a 5, because I care about my health and would love to take some weight off these knees.

Asking patients why they did not respond with a lower number will elicit motivational information; asking about what it might take to shift their response to a higher number will elicit information about barriers. This same process can be applied to the two ‘importance’ and ‘confidence’ questions above as well.

Patients Who Are Not ReadyPatients who are not ready to change can have interventions that focus on helping them move to the next stage of change by:

• Increasing hope • Building self-confidence • Exploring their personal barriers

Keep in mind that many people already want to lose weight and eat healthier, but are discouraged because of past attempts and failures. So in addition to the motivation to try again, they need confidence and hope. Communicating your certainty that weight loss if possible can help build hope.

QUIZ: ELICITING THOUGHTS, FEELINGS Ms. Campbell

Eliciting– Use questions to guide the patient in stating feelings and goals

Make A Suggestion: What could you say to try to elicit Ms. Campbell's current thoughts or



feelings about her weight-loss diet failure, recent weight gain, or attempting weight loss?

Response:

SUGGESTED ANSWER What do you think has contributed to your weight gain these past few months?

REFLECTIVE LISTENING

Use Reflective ListeningDEFINITION Listening carefully to what the patient says, then summarizing or paraphrasing it.

Rationale: Reflective listening shows them that you are listening and trying to understand them. It is one of the most powerful techniques for building rapport.

Reflective listening also demonstrates to the patient whether the doctor accurately understands the patient's view and gives the patient a chance to clarify your understanding. Listening carefully to the patient will help you know what is working for them and what is not (Miller & Rollnick, 2012).

Reflections should be statements that mirror the content or emotional tone of the patient's words. They should not be questions.

Reflective statements should be non-judgmental, even if you do not agree with the patient. To help you do this sincerely and honestly, add phrases such as, "It sounds like you feel..." or, "So, the way you see it is..."

EXAMPLE OF REFLECTIVE LISTENING

Ms. Campbell: I thought there was nothing I could do to lose weight wheneverything I've tried before, eventually failed, but you're giving me hope that theremight be some things I can still do.

Provider: That is an important step, going from thinking you cannot do anything tolose weight to realizing there are things you can do and there is hope. [Reflective listening].

When to Use This SkillReflective listening is helpful in all steps when motivating patients, but can be especially effective in Engaging the patient and when Eliciting the patient's thoughts and feelings.

REFLECTIVE LISTENING TIPS

Tips on Refining Reflective Listening• Pay more attention to the patient's statements about being willing to change and less to their

talk about not changing, without ignoring their concerns regarding not changing.

• Occasionally reflecting emotions, especially those that are apparent but not spoken, can be a powerful motivator.

Ms. Campbell: [With tears in her eyes] Losing weight would mean I might livelonger and see my grandchildren grow up and I might have less pain.



Provider: It looks like these benefits of losing weight mean a lot to you.[Reflective listening].

• Summarizing key insights from the patient periodically is another way to do reflective listening.

Ms. Campbell: Along with the health issues, my son is getting married this summer and I'd like to look good. Maybe wear a more form-fitting dress so I could look respectable.

Provider: So you found at least several reasons for working on losing weight: A longer life, less pain,and wearing the dress you want at your son's wedding. [Reflective listening].

• Offer more reflections than questions, because questions can slow momentum that is building toward change.(Rollnick et al., 2008)

TAILORING APPROACH BY STAGE OF CHANGE

Assessing Ms. Campbell's Readiness to ChangeEarlier, the provider determined that Ms. Campbell's readiness to try to lose weight was at a 5 out of 10. In the subsequent interview, Ms. Campbell sounded like she is thinking of taking some action; however, her plan is still vague and she has some ambivalence.

Tailoring the Dialogue to Ms. Campbell's ReadinessThe following dialogue illustrates how to consider Ms. Campbell's stage of change while guiding her toward a clearer plan within a time frame. The aim is to help her move along in her process of change. Goals work best if they include several characteristics, represented by the acronym SMART: specific, measurable, achievable, relevant and time-bound.

EXAMPLE OF TAILORING TO PATIENT READINESS

Provider: What kinds of activities were you thinking you could start to do at this point?[Specific].

Ms. Campbell: Well, I remembered that I can still swim, and I enjoy it, too.

Provider: Good! I'd love to see you get started swimming. Realistically, what could youdo in, say, the next two weeks to move toward that goal of swimming? [Guiding the patient to set a SMART goal - specific, measurable, achievable, relevant, and time-bound].

When to Use This Skill

Tailoring weight management interventions to the patient's stage of change is especially helpful in theFocusing and Planning steps. It also helps with the other steps of Motivational Interviewing.

MORE REFLECTIVE LISTENINGIn the following dialogue, having already set a goal for physical activity, the provider turnsto discuss dietary change and behavioral supports. The provider continues to use theskills that have been presented in this case:

Ms. Campbell: I stopped caring about what I ate when my knees started hurtingso bad. I haven't really been able to motivate myself to stand in the kitchen and cook. I have always had a sweet tooth and love sodas.



Provider: It sounds like your knee pain does have a major impact on your weight. [Reflective listening: Paraphrasing patient's words] I'd like to support you in finding creative ways around that and to brainstorm what you can about that "sweet tooth."

Ms. Campbell: I want to feel good about myself and control what I eat, but I live alone and there's no one to help me stay motivated. I find joy in good food.

Provider: So feeling good about yourself is important to you, but you have a hard time when you're not accountable to anyone and you have trouble staying motivated? [Reflective listening: Reflecting the patient's words and emotional tone back to her]

Ms. Campbell: Right. I'm motivated, but not every day.

Provider: It's hard for anyone to stay motivated all the time and to make a huge lifestyle change on his or her own. I can recommend some programs that can give you the support, so you are not going it alone. Can we talk about them? [Asking permission before making a referral].

MS. CAMPBELL: CASE SKILLS REVIEW

M.I. STEPS: SKILLS LEARNED IN THIS CASE:

Engage: Building rapport by showing concern for the patient's well-being

Focus:Bringing up the topic of patient weight

Determining readiness to change

Elicit Motivational Statements:

Using open-ended questions

Using reflective listening and summarizing a patient's most important motivators throughout the motivational counseling

Using affirmations, normalizing, reassurance, and empathy to engage the patient and to respond. These skills are used when eliciting their feelings.

Tailoring motivational dialogue to the patient's stage of change regarding weight loss

Plan for Change:Tailoring weight management plans by stage of change

QUIZ: MOTIVATIONAL SKILLS

A patient tells her provider:

Patient: I'm starting to think I'll always be fat. How can I lose weight?

Question: Which of the following provider responses are likely to be effective in terms of patient motivation? (Choose all that apply)

1. I'm glad to hear you ask. That shows that even though you are discouraged, you have some confidence that you can make changes that will improve your health.



• Feedback: • Good choice. This doctor used reflective listening ("you are discouraged") and included

an affirmation ("I'm glad to hear you ask...you've got some confidence") 2. Have you considered swimming? You might be able to do that since the water takes some

stress off your joints. • Feedback: • This comment is directive and not an open-ended question.

3. What activities do you find that you can still do on most days? • Feedback: • Good choice. This is an open-ended question.

4. I'd like to summarize: You have to eat a diet of fewer calories and get more physical activity in order to lose weight.

• Feedback: • Incorrect. This is a provider-directed rather than patient elicited plan. When

"summarizing" as a motivational technique, summarize the patient's words and feelings, not your own.

CASE #2: MR. MURPHYThis case demonstrates the use of all the steps of motivational interviewing: developing rapport, focusing on the topic of weight, eliciting thoughts and emotions, and developing a plan for weight loss.

Case ScenarioPatient Name: Alan Murphy Age: 60 y/o

Height: 5'8” Weight: 235 lbs BMI: 35.7 kg/m2 Waist: 39.5"


Chief Complaint: Physical exam, reports being a little "out of shape"

History of Present Illness: He has not been evaluated medically in over 8 years. He gets more winded with exertion than he used to but attributes it to age.

Medical History: Alcohol: Drinks 2 to 3 mixed drinks/glasses of wine, several times per week. Otherwise not significant.

Weight History: Long, slow weight gain throughout adulthood.

Physical Activity Level: Low, only walks to and from his car

Weight-Related Diagnosis: E66.9 Obesity, unspecified








ENGAGING THE PATIENTWhen engaging the patient to start a discussion of their weight, which is a sensitive topic for many people, first build rapport and ask permission to avoid setting up patient resistance.

Build RapportEstablishing rapport decreases defensiveness and increase openness to the possibility of change. Expressions of acceptance and affirmation are important parts of building rapport (Rollnick et al., 2008). Make sure to:

• Be reassuring: Reassurance that you are not going to insist on immediate and drastic lifestyle changes — you just want to talk — may also help.

• Use non-threatening body language: Pay attention to your body language. Adopt open, non-authoritarian body language. For example, sit at the same level as the patient, maintain regular eye contact, keep your chest and hands open, and do not cross your legs. Be relaxed while professional – the demeanor will likely be contagious.

Ask PermissionAsking permission engages patients by getting them to "buy-in" to the process. This approach helps the patient realize they have a say in what happens.

(Rollnick et al., 2008)

EXAMPLES OF DEVELOPING RAPPORT AND ASKING PERMISSION

Provider: I appreciate the way you check in with me every year. That way, if there areany health problems or potential health problems, I can work with you to address themearly. [Building rapport using affirmation]

Mr. Murphy: Sure, I think it's important to get checked out regularly.

Provider: One thing we could work on together that is likely to improve your health, now and down the line, is your weight. Can we talk about that? [Asking permission]

Mr. Murphy: Yes, I know I'm a little out of shape.

PRACTICE TIPWhen giving factual advice, asking patients their response to it helps engage them.

QUIZ: PATIENT AWARENESS Mr. Murphy: I don't really think of myself as overweight. I thought I was just a fewpounds up. You think it's that bad?



Question: Mr. Murphy's minimization of his weight problem could come from lack of awareness, denial, or resistance. Reasons for resistance or denial include not wanting to face painful criticism from self or others, frustration at failed weight attempts, or embarrassment in discussing weight with others.

Keeping these reasons in mind, how would you respond to Mr. Murphy's statement that he doesn't think of himself as overweight, even though he is obese according to his BMI?

Choose one

1. Just because you may have failed at dieting in the past does not mean that you are going to fail again.

• Feedback: • This statement appears to be an attempt at encouragement, which is important.

However, it is not empathetic or normalizing. Furthermore, saying "you failed" sounds critical and could end the conversation.

2. Most people gain some weight slowly as they get older. It can creep up on you and start affecting your health without you realizing it. Would you be interested in looking at how your weight compares to that suggested for your height?

• Feedback: • This approach uses the Motivational Interviewing approach of "normalizing" the

patient's experience to lower their embarrassment, self-criticism, and defensiveness. This approach also asks patient permission to discuss the topic.

3. Despite your perception, your weight means that you are obese. • Feedback: • While part of empathy includes acknowledging the patient's perspective, this statement

invalidates the patient's perspective. It is also very directive rather than taking a patient-centered approach and facilitating patient insight. Furthermore, many patients prefer that their weight problems be discussed like any other medical condition, as something they have that is affecting them rather than something defining them ("you are obese").

4. Would you be willing to work with me to develop an individualized weight loss plan that would fit with your lifestyle and food preferences?

• Feedback: • This statement doesn't address the challenge of raising Mr. Murphy's consciousness

without making him uncomfortable. This suggestion would be a good next step after Mr.Murphy's awareness of his weight problem is raised, however.

5. I understand your point of view, but the truth is that you need to go on a diet. • Feedback: • While this statement attempts to show understanding, it is too directive.

BUILDING CONFIDENCEPatients do not have to be 100% motivated or confident in their ability to change in order for change to occur. Just talking about it can help patients find motivation, gain confidence, and be more receptive to a recommendation for intensive treatment.



Describe or elicit from the patient things to build their confidence including:

• Other health habits they have changed successfully • Your experience with watching patients who were successful in weight loss • Your confidence that evidence-based models are effective when followed

EXAMPLE OF NOTING PATIENT STRENGTHS

After Mr. Murphy has become aware of his weight, the provider suggests a potentialweight-loss plan:

Mr. Murphy: I'm not so sure I could do that dieting. I've seen friends try toand it's rough!

Provider: I know you have some inner strength you can draw on because you successfully quit smoking 5 years ago, and that isn't easy. [Paraphrasing & recognizing the patient's strengths]

Mr. Murphy: [nods] I guess you're right.

ELICIT MOTIVATIONAL STATEMENTSThe different aspects of motivation you can discuss with patients include their desire, needs, and reasons (Miller, 2012). The following skills can be used in eliciting motivational statements:

ElicitingElicit motivational statements, that is emotions or feelings related to his or her inner motivations for making the change (Rollnick et al., 2008), by asking questions.

Provider: How would your life be different if you lost weight?

Mr. Murphy: Well, I could be more active, get in shape.

ReinforcingReinforce motivational statements by reflecting them back to the patient, nodding, or including them in a summary (Rollnick et al., 2008).

Provider: So, you would feel pretty good to know you could get back in shape.

Mr. Murphy: Well, yeah. It would be nice not to get winded all the time when I was trying to dosimple activities. I hadn't really thought about how losing weight would probably help that.

PausingPauses are a very powerful way to draw people out without asking questions. After making a reflective statement, pause and wait patiently. Many people will fill the pause (Rollnick et al., 2008).

Mr. Murphy: I don't think I'd lose weight, Doc.

Provider: You probably have good reasons to think that [Pause....].

Mr. Murphy: [After waiting 15 seconds] I don't think I'd be good at dieting. The wife picks out all our food. I just enjoy it. It would be hard to give that up. She'd have to be part of this.

Exploring ValuesHelping the patient explore his or her values can stimulate motivation for change (Rollnick et al., 2008). Have the patient explore his or her ideal self — this will bring incongruities to light.



Provider: What is your most important reason for losing weight?

Mr. Murphy: I'd like to be around for my grandkids, and if I have health problems because of my weight that's not guaranteed.

PRACTICE TIPKeep in mind that motivational statements are about the patient's motivation for change, not the doctor's(Rounsaville, 2002).

QUIZ: ELICITING MOTIVATIONEXAMPLE OF ELICITING MOTIVATIONAL STATEMENTS

Provider: You describe a diet that includes a good variety of foods, but not manyvegetables. You also eat some fried foods, which you recognize aren't healthy...[Pauses to elicit possible motivational statement]

Mr. Murphy: It sounds like there are some things in my life that I can do tomake my diet healthier, like cutting out the french fried potatoes. I could try to start eating more vegetables.

Question: Which of the following examples of provider dialogue best elicits a motivational statement from the patient?

References: Choose one

1. If you lose 10% of your weight, your chances of getting diabetes will go down significantly. • Feedback: • This may inspire the patient, but this is not an example of eliciting a motivational

statement from the patient. 2. How much do you believe that losing weight is worth the effort?

• Feedback: • Correct. This is a good example of a question designed to elicit motivation from the

patient. 3. We have a dietitian in our practice who can meet with you to give you support in making

healthy changes like that. Would you like to hear more about that? • Feedback: • This covers important information but does not elicit motivational statements from the

patient.

WORKING WITH AMBIVALENCE

Elicit and Facilitate Articulation of AmbivalenceHelp the patient explore, articulate, and clarify any ambivalence he or she may have about changing their eating and exercise habits. One way ambivalence can be resolved is when a person realizes that the long-term outcome is more valuable than short-term benefits (Rollnick et al., 2008; Miller &



Rollnick, 2012). For example, a patient may realize that the long-term outcome of losing weight and being healthy is more valuable than the short-term pleasure of overindulging.

Provider: It sounds like you want both to lose weight and to have the pleasure of indulging in your favorite foods.

Mr. Murphy: I see the conflict clearly when you put it together like that – Guess I can't have it both ways. In the long-run, I'm better off if I lose the weight so I'd better go more in that direction.

Facilitate Exploration of Both Sides of the AmbivalenceThis approach, Decisional Balancing, explores how each side has benefits and costs and helps clarifythe patient's confused thoughts and feelings. Exploring the pluses of continuing the unhealthy behavior before talking about the minuses lowers patient resistance (Rollnick et al., 2008; Miller & Rollnick, 2012). Focusing on the urgency of the problem or just talking about the benefits of change tends to increase resistance.

Provider: You probably get something out of avoiding weight loss. Can you tell meabout that?

Mr. Murphy: If I avoid weight loss, I don't have to give up things I enjoy, likefoods I love and hanging out with friends at places I'd be tempted to eat a lot.

Provider: I understand not wanting to give up things you enjoy. And what's not so good about avoiding weight loss?

Mr. Murphy: The big thing is what you're always talking about: My health suffers because I'm overweight. I guess I could cut back on my eating some because I do want to live a long life.

Summarizing both sides of the ambivalence also helps resolve it. Observe how the two sides of the ambivalence do not fit with each other and ask how the patient wants to resolve the apparent conflict.

PRACTICE TIP• Highlight discrepancies in what the patient says in order to produce internal tension that can

lead to change.

QUIZ: RESOLVING AMBIVALENCECase: Working With Ambivalence

Ambivalence comes from having conflicting goals (Rollnick et al., 2008). A patient may want the immediate satisfaction of overindulging in food, but also want the benefits of weight loss.

Ambivalence, or a lack of resolve, is an obstacle to change that must be resolved (Rollnick et al., 2008). Helping a patient identify ambivalence can create internal tension, which can lead to resolutionand change.

Mr. Murphy: I do want to eat healthier, but my wife and I really like eating out.

Make A Suggestion: What might you say to Mr. Murphy to help him see his ambivalence and resolve it?

SUGGESTED ANSWER



Okay, can you describe the best things about going out to eat? And what matters most to you about eating healthier?

CASE: WORKING WITH AMBIVALENCEIDENTIFYING AND EVALUATING AMBIVALENCE

Mr. Murphy: I do want to eat healthier, but my wife and I really like eating out.

Provider: Okay, can you describe the best things about going out to eat?[Exploringone side of the ambivalence, starting with the positives]

Mr. Murphy: It means my wife doesn't have to cook. We enjoy getting out ofthe house, having some drinks and relaxing.

Provider: So, it's a comfortable, enjoyable activity for you and your wife.[Reflective listening] What about the other side? What's not so good about going out to eat? [Exploring the other side of the ambivalence]

Mr. Murphy: Well, I end up eating less healthy food and lots of it and drinking more. Then I gain weight. Now I have to consider that I don't want to get diabetes.

Provider: The tradition of going out to eat with your wife seems important to you, but you understandthat some of your eating and drinking patterns are having a negative effect on your health.[Reflective listening and highlighting ambivalence] What do you make of that? [Working with the patient's ambivalence, moving toward resolution]

Mr. Murphy: I suppose I could eat better and drink less when we go out.[Success in eliciting from the patient a plan for behavior change!]

MR. MURPHY: SKILLS REVIEW

Review the Skills Used in Motivational Interviewing (M.I.)M.I. STEPS: SKILLS LEARNED IN THIS CASE:

Engage:Creating an atmosphere in which the often sensitive topic of weight can be discussed

Focus:Raising the patient's awareness of his or her's weight problem by dealing with denial or lack of awareness

Elicit Motivational Statements:

Assessing the patient's motivation to improve weight or change eating and exercise habits

Evaluating the patient's ambivalence about changing behaviors to improve health

Plan for Change:Facilitating the patient in developing a plan for changing their eating patterns



CASE #3: MR. HARRISThis case focuses on developing further skills in applying the third step of motivational interviewing, eliciting thoughts and evoking emotions. These skills include ways to address some of the more challenging situations, such as when a patient seems resistant.

Case ScenarioPatient Name: Abe Harris Age: 50 y/o



Chief Complaint: Follow-up on multiple chronic medical problems.

History of Present Illness: Unknown

Medical History: Currently being treated for GERD, depression, sleep apnea, hypoventilation syndrome, gallstones, hypertension, diabetes, hypogonadism, and dyslipidemia. Attributes his depression to weight bias experienced socially and at work.

Weight History: Started a medical weight-loss program in 2013, but gradually "lost steam."

Physical Activity Level: Only 2 hours of low-intensity walking per week.

Weight-Related Diagnoses: E66.01 Morbid Obesity; E65 Localized Adiposity (Central)






MR. HARRIS' WEIGHT HISTORY

WEIGHT HISTORY: Abe HarrisBMI: 43.2 (Class III Obesity) HEIGHT: 5'11" WEIGHT: 310 lbs

History of Significant Changes in Weight Over Lifetime: Overweight since childhood, with steady

weight gain peaking in his late 40s at 44.1 km/m2 (Class III Obesity).

MAXIMUM WEIGHT: 316 lbs, 2013 WEIGHT AGE 20: 250 lbs, 1975 WEIGHT ONE YEAR AGO: 299 lbs EPISODES OF RAPID WEIGHT GAIN AND RELATED TRIGGERS: His weight increased in 2013 asa result of family gatherings and being exposed to his favorite foods on a constant basis.

Waist Circumference: 49", 2014



Family History of Overweight/Obesity/Metabolic Disease: Both father and mother are considered obese, along with aunts and uncles who are overweight or obese.

History of Weight-Loss Attempts:

• MOST RECENT WEIGHT-LOSS ATTEMPT: Started a medical weight-loss program in 2013, with regular low-impact cardiovascular exercise and calories restricted to 1,500 calories per day. Lost 11 lbs quickly, but lost interest as weight loss slowed and quit after 5 weeks.

• PAST WEIGHT-LOSS ATTEMPTS: No other serious weight-loss attempts.

Foods Often Craved: Soda, salty snack foods, fatty meats, especially bacon and ribs.

Eating Patterns: Most of his social activities center around food. Bouts of binge-eating when depressed. Eats large portions, especially at buffets and parties.

Physical Activity: Has difficulty motivating himself to exercise. Currently unable to afford a gym membership.

• EXERCISE: "Not much to speak of" • SEDENTARY BEHAVIOR: Remains seated for the majority of the workday as a guidance

counselor and also stays seated most of his evenings.

UNDERSTANDING THE PATIENT'S VIEW

Understanding Frame of ReferenceIt is important to understand the patient's frame of reference (Rollnick et al., 2008) when assessing their weight and health problems. This is primarily accomplished through the basic skill of reflective listening (discussed earlier in the module).

Labeling weight as a problem, before the patient comes to view it that way, may work against establishing rapport; rather, the provider can simply describe the behavior instead. An example of thiscan be saying "How long have you been this weight?" instead of "How long have you had this problem?"

EXAMPLE OF UNDERSTANDING THE PATIENT'S PERSPECTIVE

Mr. Harris: My friends would be annoyed at me if I didn't order any food at ourweekend get-togethers!

Provider: It sounds like they're an important part of your life. Any plans you come up withto lose weight will probably have to include telling your friends and getting their support.[Understanding frame of reference]

Mr. Harris: I also don't have the time to get my stomach stapled.

Provider: I am glad you let me know. Let's keep that in mind as we talk. [Understanding frame of reference]

PRACTICE TIPSIdentify barriers for the patient to making the recommended lifestyle changes or treatments, such as financial limitations, and then support the patient in brainstorming about solutions.



Direct patients to interventions that are more likely to be successful in their community. For example, in many African-American communities, church-based weight-loss programs have proven effective (Kim et al., 2008).

QUIZ: RESPONDING WITH EMPATHYQuestion 1 of 1

Obese patients may experience emotional and physical discomfort if medical practicescannot accommodate their size. Waiting area chairs, exam tables, and blood pressurecuffs may not be large enough or scales may not support their weight or go highenough.

Provider: We've seen you in the past for sleep apnea, gallstones, GERD, hypertension, and dyslipidemia, but not for several years. I'm glad you came back because regular follow-up of these chronic conditions is important. [Affirmation takes the "sting" out of this observation, that otherwise might feel critical.]

Mr. Harris: I stopped seeing my last doctor because I felt embarrassed that he didn't have a scale that went high enough or a large enough blood pressure cuff for me.

Question: Of the following choices, which is the best Motivational Interviewing response?

Choose one

1. I am sorry that happened, but those are all indications that you need to lose weight. • Feedback: Partially correct. While the statement is compassionate, it is not empathetic.

Empathy involves acknowledging patient feelings from the patient's perspective. Additionally, the second half of the statement is authoritarian rather than encouraging of patient insight.

2. To prevent uncomfortable situations like that, you need to lose weight. • Feedback: Partially correct. The statement does acknowledge that the situation was

emotionally painful for Mr. Harris. However, it is very directive and not patient-centered.3. How about using that experience to lose weight?

• Feedback: Partially correct. While this does attempt to motivate the patient, it does not express empathy. Ignoring the patient's expression of discomfort like this could harm patient rapport.

4. Clearly, that doctor does not respect obese patients. • Feedback: Partially correct. This statement does make an attempt to acknowledge the

painful situation that was described. However, it does not express empathy and lacks professionalism in making a presumptive criticism of the previous doctor.

5. That experience must have been very difficult for you. I applaud your courage for coming to my office.

• Feedback: Correct! This statement expresses empathy and affirms Mr. Harris' willingness to see his provider.



AVOIDING RESISTANCE

Overcoming ResistanceResistance is a product of the interaction between you and your patient, not just a trait of the patient (Rollnick et al., 2008). Resistance may be a signal that the practitioner has assumed the patient is more ready for change than is actually true. To avoid resistance:

• Keep in mind that the patient is responsible for the decision to change. • Invite patients to consider a different perspective, but don't impose it on them. • Monitor the patient's readiness for change and don't push prematurely. • Affirm for patients that they have freedom of choice and self-direction.

(Rollnick et al., 2008; Miller & Rollnick, 2012)

Provider: What do you feel prepared to change right now?

Mr. Harris: I could probably cut out the sodas like we were talking about.

ReframingReframing is an approach that changes perspective, usually from looking on the dark side to looking on the bright side. It can help when a patient seems stuck with a negative point of view. Invite patientsto look at something from a new perspective or with a new organization: one that helps them get unstuck and move toward change (Rollnick et al., 2008; Miller & Rollnick, 2012). Emphasize the positives of the new perspective while acknowledging any downfalls.

Provider: It may seem like all those weight-loss diets were "failures." But if you think about it, with each attempt, you learned something important about yourself and about what helps you live a healthy lifestyle.

Mr. Harris: I never thought about it that way.

DE-ESCALATING RESISTANCEOnce a patient acts resistant, the best approach is to not challenge it (Miller & Rollnick, 2012). Confronting a patient's resistance can serve to increase it. Resistance may show up in different forms:

• "No" Talk: When a patient resists any proposed treatment suggestions. • "Sustain" Talk: When patients describe their reasons to sustain an unhealthy behavior.

Responding to "No" TalkA patient may reject all suggestions for addressing weight problems. One possible response is to acknowledge the patient's frustrations or statements of other emotions.

Mr. Harris: I've tried to lose weight before, but it's always ended up withme failing and that just makes me feel worse, so I eat more. It's a never-endingcycle. So, no, I'm not interested in going on a diet right now.

Provider: It sounds like you've had a lot of disappointments trying to lose weight. Ican see why it is difficult to think about trying again. Can we work together to find something you can do now, no matter how small? The important thing is to get started in a healthy direction.



Responding to "Sustain" TalkWhen a patient describes a need to maintain current eating habits, try to discover their motivation to continue the unhealthy behavior. First, acknowledge that their feeling is valid. Then turn the patient's "Sustain Talk" into "Change Talk" by asking questions about the opposite of their sustaining motivation.

Mr. Harris: I don't want to take weight-loss medications because of the risks. I can't change my eating habits, because I love eating too much. I grew up on pork fat.

Provider: I understand your concern about risks with medications and that the pleasure of eating makes it difficult to change what you eat. On the other hand, what motivation do you have toward making some changes to lose weight?

Mr. Harris: Well, I don't want to end up with an amputation from diabetes, like my brother.

ROLLING WITH RESISTANCEAnother technique for de-escalating resistance, called "rolling with the resistance," is to agree with the patient's resistance rather than proposing solutions. Paradoxically, this agreement may lead to patients coming up with solutions that counter their own beliefs, which can initiate change.

Mr. Harris: I just couldn't stand to try to lose weight and fail again.

Provider: So, based on your past experience, you are pretty sure that failing to lose weight would be more than you can bear.

Mr. Harris: Um, maybe. Well, I guess I'd be in the same boat I'm in now, so why not try...

QUIZ: PUTTING IT ALTOGETHER

The dialogue continues with Mr. Harris first expressing resistance, and then exploring personal barriers and challenges:

Mr. Harris: I've got too much going on right now. I can't make time for weight-loss surgery. [Resistance: Sustain talk]

Provider: I know it's hard to find time for surgery. It will be disruptive to your life for aperiod of time. [Empathy and reflective listening.] So if finding the time doesn't seempossible now,[Seeing from patient perspective] let's look at what other changes might be do-able untilyou can make time for surgery. [Elicit solutions from patient.] How supported do you feel by your friends and family in losing weight? [Focus on key topic.]

Mr. Harris: My friends are cool, but my family is always on my case about eating better. They worry about my health problems.

Provider: They must care a lot about you to keep trying to help. [Reframe]

Mr. Harris: I guess so. I want to lose weight, but it's hard because no one else I know has a weight problem.

Provider: I can see it would be hard to feel like you're the only one. [Empathy and reflective listening]A lot of my patients have lost weight by participating in a good quality weight loss program. Until you have time to consider surgery, I think you'd find the support you need there. [Building confidence] Would you like to hear about some of the better programs? [Asking permission. Focusing the topic.]



Question: In the above example, which of the following statements by the provider is (are) an example of "rolling with" or "going with the resistance"?

1. I know it's hard to find time for surgery. It would be disruptive to your life for a period of time. • Feedback: Correct. This comment "rolls with the resistance" by agreeing with Mr.

Harris' statement that he has no time for bariatric surgery. 2. How supported do you feel by your friends and family in losing weight?

• Feedback: Partially correct. This is a relevant, open-ended question, but it does not address the resistance.

3. Your family must care a lot about you to keep trying to help. • Feedback: Correct. This is an example of a reframe, which is another good way to

address resistance. 4. I can see it would be hard to feel like you are the only one.

• Feedback: Correct. This comment "rolls with the resistance" by agreeing with Mr. Harris' statement that losing weight is hard when he doesn't know anyone else who hasa weight problem.

DISCORD

Responding to DiscordAlthough things ended up going fairly well in the dialogue with Mr. Harris, some physicians are worried they might offend a patient and harm their relationship by bringing up a weight problem. This may or may not happen, but in the event that it does, there are some things you can do.

Signs of discord include the patient interrupting you, changing the subject, or discounting things you say. Discord will result in talking at cross purposes and not being in tune with each other (Miller & Rollnick, 2012). If you notice discord in your interactions, try one of the following:

Offer EmpathyTry backing up to the last emotional thing the person said, acknowledging it, and offering empathy (Emmons & Rollnick, 2001).

Mr. Harris: People don't understand how hard it is for me to lose weight. Theyact like I'm just lazy, but that's not it at all.

Provider: You're right. No one does know how hard it is for you. Only you know. AndI'm sorry to hear how much of a struggle it is. [Empathy]

Acknowledge the Patients' Other IssuesPatients may be more concerned about other issues in their lives, that they may perceive as more important than their weight (Emmons & Rollnick, 2001). Or other issues may be preventing them fromaddressing their weight.

Mr. Harris: It doesn't help that I'm out of work. I don't have time to worry about weight loss when I'm struggling with other financial issues.

Provider: I understand that it can be hard to focus on your health when you are out of work and worried about your finances. [Acknowledging patient's problems] Let's think about what you can do even with all that is going on in your life.



Consider Harm ReductionFor patients with serious comorbid conditions who seem resistant to change, a limited change for the purpose of harm reduction may be appropriate (Logan & Marlatt, 2010).

Provider: Would you consider just cutting down on sugary drinks as a first step? [Suggestion for harm reduction]

Mr. Harris: I guess I could try. I could go from the super-sized drinks to a smaller size.

LACK OF MOTIVATIONYou can make effective responses to patients who are not currently motivated to lose weight. Even if patients respond poorly to attempts at motivation or just are not ready to address weight loss, they should still have their weight addressed:

Make Stage of Change Appropriate RecommendationsAdvise patients lacking the motivation to at least avoid further weight gain

Mr. Harris: I just don't want to take on a weight-loss diet right now.

Provider: I understand. How about, for now, you focus on not gaining furtherweight?

Focus on Weight-Related ComorbiditiesTreat their risk factors and obesity-related comorbidities

Mr. Harris: I know I have health problems from my weight, but I just do not want to work on losing weight right now.

Provider: The best approach, for your high blood pressure, would be both medication and weight loss, but for now, we can start the medication and build toward weight loss.

Focus on Eliminating BarriersEven if patients are not ready to pursue weight loss, consider whether there are contributing psychosocial factors that might be addressed at this time. For example, depression or contributing medical factors, such as weight gain from medications or hypothyroidism or sleep apnea, could be the focus until the patient is ready to address weight loss.

Mr. Harris: I feel like, if I attempted to lose weight, I'd just be setting myself up for failure.

Provider: It is difficult to change your diet when you are unsure of your potential for success. Can wetalk about reasons you might be feeling this way?

Follow-Up at a Later DateBe sure to follow-up and ask these patients about their readiness at their next appointment.

Provider: The last time we talked, you wanted to postpone joining a weight-loss program. Have you given that any more thought?

Mr. Harris: Yes, I've thought about it and I think I'm more ready to give it a try.



MR. HARRIS: CASE SKILLS REVIEWM.I. STEPS: SKILLS LEARNED IN THIS CASE:

Engage: Looking at the problem from the patient's perspective

Focus: Avoiding resistance

Elicit Motivational Statements: Addressing resistance and discord

Plan for Change: Responding when patients still are not motivated to lose weight

VIDEO: MOTIVATIONAL INTERVIEWING - MANAGING PATIENT RESISTANCEThe following video illustrates the use of Motivational Interviewing in response to resistant patient behavior.

Video: The video “Motivational Interviewing: Managing Challenging Patient Behavior." can be found here: https://www.youtube.com/watch?v=4_q9WPTnO4k

As you watch the video, notice how the provider alternates between skills that engage and connect with the patient and those that elicit his thoughts and feelings. She skillfully uses engaging skills, suchas empathy, reflective listening, and agreeing with the patient (rolling with the resistance), in an attempt to diffuse his resistance.

APPLICATIONS CASE: MS. BENSON

Case ScenarioPatient Name: Janelle Benson Age: 31 y/o



Chief Complaint: Request fors infertility evaluation.

History of Present Illness: Has been attempting to get pregnant for two years. Notes that she has quit smoking, in order to prepare for pregnancy.

Medical History: Childbirth 4 years ago.

Weight History: Was 40 pounds overweight several years ago; weight gain of 50 pounds since then.

Physical activity level: Only 20 minutes of slow walking per day

Diagnosis: 278.00 Obesity, unspecified; 278.1 Localized Adiposity (Central)





https://www.youtube.com/watch?v=4_q9WPTnO4k




QUIZ: ENGAGING AND FOCUSINGMs. Benson

Excess weight and obesity and the resulting insulin resistance can lead to polycystic ovarian syndrome, a major cause of infertility (Teede et al., 2010).

The doctor and Ms. Benson discuss this and other possibilities and agree upon a referral to an obstetrician that specializes in fertility. The doctor then considers how best to continue the dialog to talk about weight loss.

Choose from the following provider responses to engage Ms. Benson and focus on the topic of weight.

Question: After setting Ms. Benson up with a referral for her fertility concerns, how would you first approach the conversation of weight with her? (select the best option)

Choose one

1. I'd like to talk a little about your weight gain in the last several years. Can we talk about that? • Feedback: Good choice. Asking permission to discuss weight will help build rapport.

2. I noticed you have been gaining weight. What are you doing about that? • Feedback: Incorrect. This choice jumps abruptly and insensitively from starting the

conversation to developing a plan. 3. Are you interested in losing weight?

• Feedback: Partially correct. This question does ask permission but is a yes/no questionrather than open-ended, and it omits tying weight to health concerns.

4. I noticed that you have put on some extra pounds over the past few years. You should consider losing some weight.

• Feedback: Incorrect. This approach is too directive.

QUIZ: EXPLORING PERSONAL BARRIERSMs. Benson brings up a personal barrier to weight loss:

Ms. Benson: I've been too busy to do anything about my weight.

Question: Which of the following is the best motivational question to ask Ms. Benson next?

Choose one

1. Why is your life so busy? • Feedback: Incorrect. Avoid "why" questions. They can raise patients' defenses.

2. Tell me more about the things in your life that are getting in the way.



• Feedback: Correct. This is an open-ended question and is responsive to the last thing she said.

3. It is easy to make excuses. • Feedback: Incorrect. This is not a question. This also has a critical tone that can raise

defenses. 4. What are some things you can do now?

• Feedback: Partially correct in that it engages Ms. Benson to participate. This question is not focused enough on the last thing the patient said, which was about her life being too busy to do what she needs to do to lose weight. It is important to listen to and respond to patients. It was a good approach to ask an open-ended question, however.

5. Can you spend less time going out with friends? • Feedback: Correct. This is not an open-ended question and is very directive.

READINESS, MOTIVATION, CONFIDENCEBrief Counseling Protocol Step: Assess stage of change and confidence in ability to lose weight.

Notice that before talking to Ms. Benson about motivation to change, the provider finds out if Ms. Benson is ready to lose weight – the provider does not assume that she is ready.

Ms. Benson: My daughter keeps me pretty busy.

Provider: If you are interested in talking about losing weight, we could talk about ways to do it that would not cost much time. It would reduce health risks and probably give you more energy to keep up with your daughter. Would you be open to trying to lose weight? [Determining patient readiness.]

Ms. Benson: I suppose so, it's been so hard since I quit smoking...

You can elicit from the patient things like how important it is to make a change and what makes it important to them. Read the next page to learn what happens when the provider asks Ms. Benson to rate how confident she is to make changes.

ASSESSING MOTIVATION AND CONFIDENCEThe following "trick" helps the provider assess the motivation that the patient alreadyhas. The trick is that it gets the patient to say something positive about their desire forchange, even if their motivation is low.

Provider: On a scale of 1 to 10, how confident are you that you could begin makingchanges to your diet? [Assessing confidence]

Ms. Benson: Maybe a 3.

Provider: Why not lower?

Ms. Benson: Why not lower? I thought you'd ask "Why not higher?"

Provider: No, I am interested in why you did not rate yourself lower. You must have at least some motivation and confidence or you would have said "1."

Ms. Benson: I never thought about that. I suppose it's because getting pregnant and the rest of my health is important to me. I already do make some effort, even though I'm too busy. I guess I dohave some confidence that I can do this! [Notice how tapping into feelings of strong motivation gave her confidence.]



QUIZ: ELICITING IDEAS, FEELINGSThe provider continues a conversation with Ms. Benson, applying the 3rd step of Motivational Interviewing which is to evoke patient feelings and eliciting their thoughts. In this case, the provider is focused on thoughts regarding Ms. Benson's personal barriers to weight loss and then facilitating the brainstorming of solutions:

Provider: You said you have had trouble losing weight since you stopped smoking. Many people do gain some weight, but it is possible to lose weight after quitting. Tell me more about the things in yourlife that are getting in the way.

Ms. Benson: I take care of my elderly mother and my daughter by myself. I also work two jobs. I don't have time to go to a health club and I couldn't afford it anyhow.

Provider: So, using a health club is not an option. What ways could you increase your activity, even in little ways?

Ms. Benson: I suppose I could get more involved in playing with my daughter. I usually just sit on the side and watch. I don't get much exercise in my work.

Provider: Great idea!

Question: Which of the following techniques did the provider use to elicit ideas and feelings from Ms.Benson in this dialog?

1. Rolling with the resistance • Feedback: It would be a good approach, but it was not used here. Rolling with the

resistance is an effective skill to use when a patient is resisting change. However, it was not used in this dialogue. Furthermore, Ms. Benson did not express resistance in this exchange.

2. Open-ended question • Feedback: Correct. Good! "What ways could you increase your activity, even in little

ways?" is an open-ended question. It led Ms. Benson to come up with some ideas to get more exercise. Although it is not a question, saying "Tell me more about the things in your life that are getting in the way" works in the same way to elicit ideas and feelings. Notice how open-ended questions require the patient to engage in the process of self-examination.

3. Reflective listening • Feedback: Correct! "So, using a health club isn't an option" is an example of reflective

listening. 4. Affirmation

• Feedback: Correct. Yes! Saying, "Great idea!" affirms Ms. Campbell's ability to plan changes in her behavior that will contribute to weight loss.

QUIZ: EXPRESSING EMPATHYQuestion: Which of the following statements is an example of expressing empathyeffectively with Ms. Benson?



Choose one

1. I bet your daughter misses you. • Feedback: Partially correct. This shows concern for Ms. Benson but misses the point of

what was bothering her most at this time: her busy schedule and how difficult that makes it to lose weight.

2. Are these jobs stressful? • Feedback: Partially correct. Stress might be relevant to her weight gain, but this does

not respond to Ms. Benson with empathy. 3. So you do a lot of sitting, that can have negative effects on your health.

• Feedback: Partially correct. This is a correct statement of fact that might be relevant to Ms. Benson's weight gain but does not convey empathy.

4. It sounds like you are responsible for quite a lot. • Feedback: Correct. This statement conveys empathy in direct response to Ms.

Benson's greatest expressed concern, her busy schedule.

REFLECTIVE LISTENINGIn the following dialogue, notice how the provider listens carefully to what Ms. Benson says and then summarizes or paraphrases the idea the patient communicated. This shows patients that the provideris listening and trying to understand them.

Provider: It sounds like you are responsible for quite a lot! But, keep in mind, you need to take care of yourself, too, so you can be there for your family. [Pauses]

Ms. Benson: I'm not really happy about my weight. I want to look better. I've been thinking about trying to turn things around, but I haven't done it yet. I had been thinking it wouldn't be possibleto lose weight after quitting smoking so it's good to know you think it is possible.

Provider: [Summarizing] It is, absolutely! So you are starting to think about losing weight and feeling motivated. You are heading in a good direction! There are some weight-loss programs that provide support and have been shown to make a difference for many people trying to lose weight. Can we talk about them?

QUIZ: EVALUATING AMBIVALENCE

Highlighting any ambivalent feelings that patients may have can motivate them towardchange. Ambivalence is uncomfortable, so just bringing their attention to it can beenough to motivate change.

Ms. Benson: I know I should eat vegetables and fruits, and my daughtershould, too. But with limited time and lots of stress, I find I just want comfort foods. Youknow, fried foods and potatoes.[Note: The patient has expressed ambivalence]

Challenge: Improve the following dialogue:

Provider: Weight loss is not easy. You will have to make certain sacrifices.

Ms. Benson: It's not like I don't try!



Question: The last exchange between the provider and the patient did not go well. What could the provider have said instead of "Weight loss is not easy. Will you have to make certain sacrifices"?

Choose one:

1. Part of you would like you and your daughter to eat healthier, and part of you wants to soothe your stress with comfort foods.

• Feedback: Correct. This approach skillfully builds the tension in the ambivalence, so that Ms. Benson will be more motivated to resolve the ambivalence herself. You can support her by adding, "How could you resolve this conflict?"

2. You are going to have to decide what is most important to you. • Feedback: Partially correct. This responds to the ambivalence but could be more skillful

in building the tension between the conflicting desires, so that the patient is motivated to resolve the ambivalence herself.

3. You need to think about how you are a role model for your daughter and she is learning food habits from you.

• Feedback: Incorrect. This approach is too directive. 4. Exercise can be more fun and easier than you think.

• Feedback: Incorrect. This approach is too directive. 5. It is important that you get your weight problem under control. You will need to make changes.

• Feedback: Partially correct. This responds to the ambivalence but could be more skillfulin building the tension between the conflicting desires, so that the patient is motivated to resolve the ambivalence herself.

QUIZ: PLAN FOR CHANGEMaking a plan: The next step in motivational interviewing is to work with the patient to make a plan to address the issues that have been discussed, based on what has been revealed in the session.

Make A Suggestion: What could you say to guide Ms. Benson toward developing a plan for change?

SUGGESTED ANSWER Ask Ms. Benson, “Which of the changes we have discussed could you see yourself starting within a week or two?”

PERSONALIZED PLANBrief Counseling Protocol Step: Facilitate behavioral change goal setting.

Collaborate with the Patient to Create a Personalized Plan for ChangeMs. Benson is guided to come up with her own plan for change, which is step four and the final step of motivational interviewing. In the following dialogue, the provider elicits a plan from the patient for a limited period, from a couple of weeks up to around 90 days. The time frame depends upon her support system and when the provider will next see the patient.

Provider: Tell me, what steps are you ready to take in the next month towards improving your diet and activity level?



Ms. Benson: I suppose I could start cutting my portion sizes down, but I wouldn't know whereto begin to change all my recipes.

Provider: Cutting your portion sizes down sounds like a great start. Part of successful weight loss formost people is getting enough support in making the kind of lifestyle changes we've been talking about. How much support do you have already?

Ms. Benson: There is a community center program that has classes on cooking for health. They also have a walking club. I could join that.

Provider: Good! And Ms. George will help you get an appointment with the obstetrician specializing in fertility to find out if hormonal imbalances are contributing to your difficulties in getting pregnant. Whether or not that is the problem, weight loss will be important.

CLINICAL PROTOCOL STEPS IN THIS MODULEThe following Clinical Protocol Steps for patients with obesity were illustrated in this module:Brief Counseling Protocol Steps

• Use the four steps of Motivational Interviewing to facilitate advancements in stages of change as needed.

• Assess stage of change and confidence in ability to lose weight. • Facilitate behavioral change goal setting.

MODULE SUMMARY

MotivationTo motivate patients to change behaviors contributing to weight problems, you can use the following techniques from motivational interviewing:

MOTIVATIONAL STEPS:

1. Engaging with the patient 2. Focusing on the topic of weight 3. Evoking/eliciting the patient's ideas and emotions to guide them to actively examine and

resolve his or her own problem 4. Planning: Helping patients make a plan for health behavior change

MOTIVATIONAL TOPICS:

• Importance of change for the patient (motivations) • Confidence of the patient that they can change (ability and barriers) • Readiness of the patient to change (stage of change)

MOTIVATIONAL SKILLS AND PRINCIPLES:

• Use open-ended questions to draw out the patient. • Use affirmations, normalizing, reassurance, and empathy to build rapport and confidence. • Use reflective listening to build rapport and accurately understand the patient, summarizing

their words back to them.



• Elicit motivational statements from the patient about their needs, desires, ability to change/barriers to change, and reasons they might want to change.

• Facilitate the patient's evaluation of both sides of ambivalent feelings, but avoid or de-escalatepatient's resistance.

• Facilitate the patient's developing and committing to a plan for weight loss.

RESOURCES AVAILABLE THROUGH THIS MODULE:• Patient Readiness Checklist

Roadmaps for Clinical Practice: Case Studies in Disease Prevention and Health Promotion, Assessment and Management of Adult Obesity: A Primer for Physicians, Assessing Readinessand Making Treatment Decisions, Booklet 3, Assessing Readiness and Making Treatment Decisions, see page 6 to more thoroughly evaluate patient’s readiness.

• Readiness to Change Ruler and QuestionsThe readiness to change ruler is used to assess your patient's willingness to change. This canbe especially important when attempting to assist your patient with behavioral change for disease prevention, such as obesity.

REFERENCES USED IN THIS MODULE:

Practice Gaps ReferencesArmstrong MJ, Mottershead TA, Ronksley PE. Motivational interviewing to improve weight loss in

overweight and/or obese patients: a systematic review and meta-analysis of randomized controlled trials. Obesity reviews. 2011; 12: 709-723. Available at: http://www.ncbi.nlm.nih.gov/pubmed/21692966 Accessed on: 2015-03-11.

Bardia A, Holtan SG, Slezak JM, Thompson WG. Diagnosis of obesity by primary care physicians and impact on obesity management. Mayo Clinic Proceedings. 2007; 82(8): 927-932. Available at: https://www.ncbi.nlm.nih.gov/pubmed/17673060 Accessed on: 2011-10-14.

Fitch A, Everling L, Fox C. Health care guideline: prevention and management of obesity for adults. Institute for Clinical Systems Improvement. 2013. Available at: https://www.icsi.org/_asset/s935hy/Obesity-Interactive0411.pdf Accessed on: 2015-02-24.

Jay M, Kalet A, Ark T, McMacken M, Messito MJ, Richter R, Schlair S, Sherman S, Zabar S, Gillespie C. Physicians' attitudes about obesity and their associations with competency and specialty: a cross-sectional study. BMC Health Serv Res. 2009; 9(106): . Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2705355/ Accessed on: 2014-06-13.

Pollak KI, Østbye T, Alexander SC, Gradison M, Bastian LA, Brouwer RJ, Lyna P. Empathy goes a long way in weight loss discussions. J Fam Pract. 2007; 56(12): 1031-6. Available at: http://www.jfponline.com/fileadmin/jfp_archive/pdf/5612/5612JFP_Article2.pdf Accessed on: 2011-10-14.

Simkin-Silverman LR, Conroy MB, King WC. Treatment of overweight and obesity in primary care practice: current evidence and future directions. American Journal of Lifestyle Medicine. 2008;


http://www.jfponline.com/fileadmin/jfp_archive/pdf/5612/5612JFP_Article2.pdf

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2705355/

https://www.icsi.org/_asset/s935hy/Obesity-Interactive0411.pdf

https://www.ncbi.nlm.nih.gov/pubmed/17673060

http://www.ncbi.nlm.nih.gov/pubmed/21692966

https://docs.clinicaltools.com/pdf/impact-obesity/Readiness_ruler.pdf

http://www.reducingobesity.org/docs/toolkits/Health%20Professionals/Assessment%20and%20Management%20of%20Adult%20Obesity-%20AMA/Assessing%20Readiness%20and%20Making%20Treatment%20Decisions.pdf


(2): 296-304. Available at: http://ajl.sagepub.com/content/2/4/296.abstract Accessed on: 2011-10-14.

Smith AW, Borowski LA, Liu B, Galuska DA, Signore C, Klabunde C, Huang TT, Krebs-Smith SM, Frank E, Pronk N, Ballard-Barbash R. U.S. primary care physicians' diet-, physical activity-, andweight-related care of adult patients. Am J Prev Med. 2011; 41(1): 33-42. Available at: http://www.ncbi.nlm.nih.gov/pubmed/21665061 Accessed on: 2011-10-14.

STOP Obesity Alliance. Provider/Patient Survey on Obesity in the Primary Care Setting. STOP Obesity Alliance. 2010. Available at: http://www.stopobesityalliance.org/research-and-policy/research-center/survey-results/ Accessed on: 2011-10-14.

Tanner B, Metcalf M. Needs Analysis. Improving Obesity Outcomes Through Interactive Web-Based Clinical Skills Training. 2011. Accessed on: 2015-02-23.

Module Content ReferencesClinical Tools, Inc. Motivational Interviewing. Clinical Tools, Inc.. 2016. Available at:

https://www.youtube.com/embed/cOlb7ADwsMw Accessed on: 2016-01-08.

Clinical Tools, Inc. Motivational Interviewing: Managing Challenging Patient Behavior. Clinical Tools, Inc.. 2016. Available at: https://www.youtube.com/embed/4_q9WPTnO4k Accessed on: 2016-01-08.

DiLillo V, West DS. Motivational interviewing for weight loss. Psychiatric Clinics of North America. 2011; 34(4): 861-869. Available at: http://www.ncbi.nlm.nih.gov/pubmed/22098809 Accessed on: 2017-08-16.

Emmons KM, Rollnick S. Motivational Interviewing in Health Care Settings: Opportunities and Limitations. American Journal of preventive medicine. 2001; 20: 68-74. Available at: https://meded.duke.edu/practice/wp-content/uploads/2012/09/Emmons-MI-article1.pdf Accessed on: 2014-07-17.

Kim KH, Linnan L, Kramish Campbell M, et al. The WORD (wholeness, oneness, righteousness, deliverance): A faith-based weight-loss program utilizing a community-based participatory research approach. Health Educ Behav. 2008; 35(5): 634-50. Available at: https://www.ncbi.nlm.nih.gov/pubmed/17200103 Accessed on: 2014-06-18.

Logan DE, Marlatt GA. Harm reduction therapy: a practice-friendly review of research. Journal of clinical psychology. 2010; 66(2): 201-214. Available at: http://onlinelibrary.wiley.com/doi/10.1002/jclp.20669/abstract Accessed on: 2015-03-18.

Miller WR, Rollnick S, Moyer TB. Motivational interviewing: preparing people to change. Universityof New Mexico. 1998. Available at: http://www.worldcat.org/title/motivational-interviewing-preparing-people-for-change/oclc/265034709 Accessed on: 2013-06-19.

Miller WR, Rollnick S. Motivational Interviewing. Helping People Change. Applications of Motivational Interviewing Series. New York: Guilford Press. 2012; 3rd edition: . Available at: http://www.guilford.com/books/Motivational-Interviewing/Miller-Rollnick/9781609182274 Accessed on: 2014-07-08.


http://www.guilford.com/books/Motivational-Interviewing/Miller-Rollnick/9781609182274

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http://www.worldcat.org/title/motivational-interviewing-preparing-people-for-change/oclc/265034709

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https://www.youtube.com/embed/4_q9WPTnO4k

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http://ajl.sagepub.com/content/2/4/296.abstract


Rahm AK, Boggs JM, Martin C, et al. Facilitators and barriers to implementing SBIRT in primary care in integrated healthcare settings. Substance Abuse. 2015; 36(3): 281-8. Available at: http://www.ncbi.nlm.nih.gov/pubmed/25127073 Accessed on: 2015-05-27.

Rollnick S, Miller W, Butler C. Motivational Interviewing in Health Care. Guilford Press: New York. 2008. Available at: http://books.google.com/books?id=njcm0V_IprEC&dq=Using+motivational+interviewing+in+routine+care&lr=&source=gbs_navlinks_sAccessed on: 2014-12-16.

Rounsaville BJ. Using Motivational Interviewing in Health Care. 2002. Available at: http://archives.drugabuse.gov/pdf/blending/Rounsaville.pdf Accessed on: 2014-02-19.

Westra HA. Motivational interviewing in the treatment of anxiety. Guilford Press: New York. 2012. Available at: http://www.guilford.com/books/Motivational-Interviewing-in-the-Treatment-of-Anxiety/Henny-Westra/9781462525997 Accessed on: 2015-06-25.


http://www.guilford.com/books/Motivational-Interviewing-in-the-Treatment-of-Anxiety/Henny-Westra/9781462525997

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