At the start of a dietetic internship, students have often had no experience in effective counselling. At our hospital, students must complete a 3 week diabetes rotation and this is a very limited amount of time to develop confidence in this area. Most student learning at university was in lecture format and students often begin the diabetes rotation by believing that the dietitian’s role is to tell clients what to do.
Dietetic interns should become involved in the counselling process as soon as possible in the rotation (even in the form of role playing). Interns have identified “an open learning environment, in which students can establish rapport, take risks and make mistakes” as qualities of an effective dietetic internship (1). Early in the rotation they can begin by participating in the opening part of the interview. The dietitian can also explain the process to the intern as the interview proceeds.
LECTURING DOES NOT WORK and is very frustrating for clients with diabetes. They do not appreciate a lecture and end up feeling frustrated that the educator does not understand how difficult it is to live with diabetes. Food is an important part of one’s life and making changes is very difficult. Focus groups of those who have received nutritional counselling have shown that dietary changes have made clients feel “angry, depressed and deprived” (2). So how does one make this experience a meaningful one in a busy clinic and introduce the idea of motivational interviewing (MI)*?
[box color=”white” icon=”accept”]*Definition: MI is an evidence-based approach to behaviour change. It draws on several existing models of psychotherapy and health behaviour change (3). One of the goals is to help individuals work through their ambivalence towards behavioural change. They do much of the work as the counsellor helps them explore reasons for and against change. [/box]
Interns agree that when they observe the dietitian conduct an interview, it looks very easy. They don’t realize that it took many years of experience and reflection to move from an advice-giving style to one that employs the techniques of motivational interviewing. MI can be particularly helpful in diabetes counselling. It uses a variety of techniques such as reflective listening, shared decision-making and agenda-setting (3). It can be useful to break the interview into 4 parts and discuss each part separately. All 4 parts take place within a single session which lasts about 1 hour in my practice.
Getting ready/setting the stage Before the client arrives, ideally the intern should be familiar with the client’s history. This includes length of time the client has had diabetes, medications, height and weight, social issues, and control (A1C, lipids, blood pressure). (I tell the intern not to be surprised if the client is on a long list of medications as this is often the norm in diabetes). When the client arrives, the dietitian should provide a quick summary of the history. For example, “I have had a look at your file and can see that you have had type 2 diabetes for 15 years. It looks like you are having difficulty with your control – does this sound right? – perhaps you can tell me what your concerns are regarding your diabetes?” Developing a rapport with the client and getting to know his/her life situation is key. The client may express concern about his control (both diabetes and cholesterol) and tell you that the large meal he eats after his evening shift is a big part of the problem. Letting the client do most of the talking is part of a successful MI session (3). At this point the dietitian can use an effective empathy technique by asking permission to set the agenda. (“Would it be alright if we reviewed when and what you eat, your medications, and your blood sugars to really understand what’s going on? Perhaps we can figure out how to improve your control. When you come for follow up, we can discuss your cholesterol”). The dietitian becomes less the voice of authority and more of an equal partner in solving a problem.
Allowing clients to decide what changes might be possible The diet history may have identified several key areas of concern. For example, the typical dinner may be very high in carbohydrate because the meal is late at night and the client has not eaten since noon. Rather than saying “your dinner is too late at night and you need to eat earlier”, the dietitian can help the client come up with their own solution. “Rolling with resistance” is a specific type of empathy where you attempt to understand resistance to change. The tone of MI is non-confrontational and non-judgemental. The dietitian can help the client express pros and cons to changing behaviour (“Can you tell me what it is you like about eating late at night?”). The client may say that the vending machine choices at work are not healthy and his wife has prepared a very healthy meal at home for him. The dietitian can ask the client to rate their readiness to change on a scale of 0 to 10 by asking “How important is it for you to change your eating pattern right now?”
Developing discrepancies Here the dietitian can help the client become aware of the discrepancy between their current behaviour and their personal goals. The client in this case puts a lot of value on good health and wants to enjoy his retirement and knows that his current situation will compromise this. The dietitian can elicit potential solutions to the problem from the client. The dietitian never tells the client what to do but serves to discuss mixed feelings and barriers to change.
Instilling confidence and goal setting A scale can be used to assess confidence in achieving a goal. For example, the dietitian can ask the client to rate his/her confidence in achieving a goal on a scale of 0 to 10 with 10 representing extreme confidence. The client may say the number is 5 and the dietitian can explore barriers to change: “What would need to change for you to move from 5 to 7?” The dietitian can summarize the client’s readiness to change and point out the pros and cons of changing the behaviour.
MI has been used in my areas of health behaviour including weight loss, exercise, addictive behaviours and type 2 diabetes. In a randomized trial of clients with type 2 diabetes, those who received additional MI sessions lost significantly more weight (4). MI has also been shown to result in a lower A1C in teenagers with diabetes (5). It can take several months to train MI to certified diabetes educators (3). MI is not for all clients with diabetes. Some prefer a more directive approach and have even stopped the interview to say “Aren’t you just supposed to tell me what to do?” or “Aren’t you supposed to just give me a diet?” It is not always possible to know which style works best for each client. It can also be difficult to use MI in clients whose first language is not English or French.
Dietetic interns can feel intimidated by this approach to counselling. It is very different from their student experience and letting the client do most of the talking takes confidence and lots of practice. However it is felt that even in brief consultations the spirit of MI can be incorporated in everyday counselling. As interns move through the different clinical rotations they become more skilled in this type of counselling.
- Kruzich LA, Anderson J, Litchfield RE et al. A preceptor focus group approach to evaluation of a dietetic internship. JADA.2003;103:884-886.
- Barr J, Schumacher G. Using focus groups to determine what constitutes quality of life in clients receiving medical nutrition therapy: First steps in the development of a nutrition quality-of –life survey. JADA 2003; 103: 844-851.
- Welch G, Rose G, Ernst D. Motivational Interviewing and Diabetes : What is it, How is it used, and does it work? Diabetes Spectrum. 2006; 19: 5-11.
- Smith West D, DiLillo V, Greene P et al. Motivational Interviewing increases adherence to a behavioural weight control program. Presentation at the North American Assoc. for the Study of Obesity Annual Meeting. Las Vegas, Nev., 14-18 November 2004.
- Channon S, Smith VJ, Gregory JM. A pilot study of motivational interviewing in adolescents with diabetes. Arch Dis Child. 2003; 88: 680-683.