Both recently certified health and wellness coaches and experienced health coaches may find themselves in situations where they feel resistance from a client to change.
Rather than assuming that the client is “difficult,” you may want to examine your coaching techniques and mindset. One technique that can help create a safe space with your client while also allowing you to understand the barriers, difficulties, and confidence levels to adopt new health behaviors is motivational interviewing.
Motivational interviewing is a technique used by health professionals to create a safe space with open communication that recognizes your clients’ agency and self-efficacy regarding the if, when, how, and what of change. It also is a space to bring the social determinants of health out into the open. Through effective motivational interviewing, you help clients verbalize barriers and other factors that are out of their control that may influence their health.
The questions in this article are based on motivational interviewing techniques for healthcare professionals.
The Power of Motivational Interviewing in Health and Wellness Coaching
In professional health settings, there are often discussions about the most effective ways to support patients or clients in adopting habits and behaviors. One of the techniques that professionals implement in healthcare settings is motivational interviewing.
Motivational interviewing has been demonstrated to support people in adopting health-promoting behaviors in clinics and the health coach’s office. It is designed to support clients in progressing through the stages of behavior change on which several health and wellness coaching programs are based—from pre-contemplation to contemplation, to preparation, to action, to maintenance.
Additionally, motivational interviewing is a space where you and your client can discuss the social determinants of health that are out of their control yet impact their health. These include economic stability, healthcare and education access and quality, and the neighborhood and built environment. By understanding the social determinants of health, during the consultation, you can validate your client’s feelings of frustration at the barriers to adopting different health behaviors. If appropriate, you may want to initiate a discussion about managing barriers to adopt health-promoting behaviors in a way that makes sense for them.
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Before Asking the Questions, Keep These Principles in Mind
Here are the fundamental principles, with sensitivity to the social determinants of health, for effective motivational interviewing:
- Use reflective listening to show empathy.
- Develop a connection between client goals and current actions, habits, and behaviors.
- Recognize that there are health behaviors that are not within the client’s control.
- Allow the client to decide if, when, and how to change and what is realistic for them on all of these fronts.
- Roll with resistance, rather than confronting or opposing it.
- Support your client’s optimism to change and self-efficacy (the perception that they are able to change), and talk through pessimism.
5 Core Skills of Motivational Interviewing
When you master motivational interviewing, you shift from being a director to a guide. Strengthening the five core skills of motivational interviewing can help you make that shift. The five core skills are:
- Asking open-ended questions: Questions should allow clients to reflect on how and why they might change.
- Listening reflectively: Understand your client’s experience, and acknowledge when you can’t due to your own implicit biases and privilege. Use reflective listening statements that show you understand what your client is going through and roll with the resistance. For example, “Cooking meals at home just feels like too much to manage right now.” Avoid offering advice here. Reflective listening shows empathy. Encourage elaboration when client’s responses are vague or when they are showing resistance.
- Providing affirmations: Affirmations are a great way to express empathy when your clients are going through a difficult time and demonstrate to your client that you recognize an aspect of their personalities or actions that might encourage them. Use them to recognize and celebrate your client’s accomplishments, including when they don’t see them as accomplishments at first.
- Inform with permission. Ask permission to provide information to your client. Give them options for where to start. After you’ve provided information on a topic, ask your client to share reflections on what they think that information might mean to them.
- Summarizing: Recap what your client expressed, and allow them to correct any misunderstandings. Depending on the goal of the session, it may be helpful to use summaries before leading into open-ended statements such as “I am wondering what you think your next step should be.”
However, keep in mind that there are several inappropriate assumptions that health professionals may have regarding their clients’ behavior change, several of which Emmons and Rollnich identify.
Inappropriate Assumptions about Health Behavior Change
- This person ought to change.
- This person wants to change.
- The health provider’s life and health experience are the same as their client’s experience.
- The health provider shouldn’t disclose personal experience when it may amplify the therapeutic potential of the relationship.
- The person’s health is the prime motivating factor to change.
- If the client does not decide to change, the consultation has failed.
- Patients are either motivated to change or aren’t.
- Now is the right time to consider a change.
- A tough approach is always best.
- I’m the expert. The client must follow my advice.
- A negotiation-based approach is best.
5 Motivational Interviewing Question Types to Support Clients in Achieving Their Health and Wellness Goals
Stephen Rollnick, MD, of the School of Medicine of Cardiff University, is one of the founders of the Motivational Interviewing method. In motivational interviewing, the coach guides the overall direction of the session but should be willing to change it based on the conversation and dynamic of the interaction, while the client controls what, how, and when to change, as well as if they want to change at all. You, as the health expert, can collaboratively offer your expertise and knowledge when the client is open to receiving it, but they have the freedom and autonomy to decide whether or not to make the change.
Rollnick suggests five different question types that will help elicit motivation to change health behaviors from the client. The motivational interviewing question types, or question strategies, have been proven to be effective among college students to reduce alcohol, tobacco, and marijuana consumption and support people with diabetes management.
Agenda-setting questions invite clients to set a goal or a plan following the session. In many cases, clients have many ideas for what they want to achieve. Having someone set goals for them will make it unlikely for them to achieve those goals. When they are invited to set their own goals, especially after an honest, reflection-focused discussion with their health coach, they will be more likely to achieve their goals and gain a sense of self-efficacy.
Some examples of agenda-setting questions:
- Thank you for sharing your thoughts with me. What do you feel most ready to focus on right now?
- What do you think your next step should be?
- What would make the most sense for you to try next?
- What sounds like a realistic next step for you?
Questions that invite an identification of pros and cons
When clients are in the contemplation and pre-contemplation stages of behavior change, it is normal for them to feel at two minds to change. Usually, they already have an idea as to the pros and cons of adopting a new health behavior, sticking to current health behavior, or reverting to previous health behavior.
This is also a good place for you to understand some of the social determinants of health that are impacting them.
Inviting clients to think about and verbalize the pros and cons of current and different health behaviors helps you understand their mindset while also opening the door to engage in a conversation about the possibility of change.
Some examples of motivational interviewing questions that invite the identification of pros and cons include:
- What types of foods seem most convenient for you to eat right now? Is there anything you enjoy about eating fresh foods?
- Is there anything you feel that is out of your control that influences your ability to exercise?
- What are some of the tricky parts of trying to stay active?
- How do you feel after you have been inactive for a few days? How about after you have been (name a physical activity they have carried out) for a few days?
- Do you see any benefits of eating breakfast before you leave the house?
- Do you see any drawbacks of not taking your medication?
Questions that assess importance and confidence
If a client is not convinced of the benefits of changing a habit, it is likely that the coach hasn’t illustrated the benefits in a way that resonates with the client. It is also unlikely that they will listen to or benefit from a coach’s advice and information about how to change. These types of questions help the coach understand whether or not the client feels making a change is important for them and whether they feel they are able to change.
Some examples of motivational interviewing questions that assess the importance of change include:
- How important is taking a vitamin D supplement/your heart pressure medication right now?
- How do you feel about switching out white bread for whole-grain bread some of the time? Do you think it will make a difference in how you feel?
- How important it is to you that you drink less?
Suppose you notice that your client doesn’t place importance on adopting a health-promoting action. In that case, you can ask them if you can provide information about that topic, emphasizing their autonomy to follow through or not. Remember to roll with resistance. Your client may not be ready to talk about changing a behavior, or they may want to dive into why they think a change is unimportant or unrealistic right now. If that is the case, you can ask them what they would like to focus on.
Some examples of questions that assess confidence to change include:
- How confident do you feel that you’d be able to walk for 15 minutes a day?
- You mentioned you’d like to eat more fresh foods on weekdays. Is it doable for you?
- How confident do you feel about taking the medication as your doctor prescribed?
Remember to summarize the patient’s point of view on importance and confidence and correct or confirm any details before asking if you can offer information.
Questions that allow for an exchange of information
Listening is at the center of motivational interviewing. Experts on motivational interviewing have developed the elicit-provide-elicit strategy. This strategy first elicits understanding, then provides information, and finally, elicits the patient’s understanding.
Here is an example of how to carry out the elicit-provide-elicit strategy to exchange information:
Elicit understanding: Would you feel comfortable if I ask about your understanding of how activity levels impact how you feel? (If permission is provided) What do you know about the risks of staying inactive for long periods of time?
Provide information: I can see how, in your line of work, getting up and moving is challenging, especially since there are few public spaces you feel are safe where you live and work. As you described, staying inactive, which is called being sedentary, can cause your blood pressure to rise and make you feel more lethargic. Over time, sedentarism could increase your risk of several diseases, including type 2 diabetes.
Elicit patient’s interpretation: Can I ask if you think this information applies to you?
In motivational interviewing, there are questions that invite clients to make decisions about change. Note that not all clients may be ready to or feel a need to change, or they may be ready to adopt some changes but not others. It is important to respond accordingly to demonstrate that you are listening to you client and respecting their autonomy.
If you notice that your client has an interest in changing a health behavior, you can lead into setting goals by:
- Summarizing the client’s situation: I hear that you want to start moving your body more, but you are unsure how you can find the time to do it while still staying on top of your responsibilities.
- Emphasizing the client’s autonomy and freedom: Ultimately, you are free to choose whether or not and when to move your body more.
- Inviting the patient to envision change: Can you envision yourself doing 10 minutes of physical activity for one day? This might look like walking to the supermarket rather than taking your car, or it could look like getting on a stationary bike while you watch the news.
- Summarizing the patient’s response: You think it’s realistic to take a walk to local shops and the pharmacy to do your errands.
- Inviting the patient to clarify what will be helpful: Some people find parking further away from their place of work helps to get their body moving. Do you think this would be useful for you?
The purpose of this sequence is to zone in on a realistic goal defined by the client, not by the health coach. Again, this process may take more than one session, especially if your client will find it helpful to bring an ally, like their partner, sibling, or a friend, to support them. It is more important to go at your client’s rhythm so that the changes are self-directed than for the coach to define a goal for them, as the coach-defined goal may be misguided or preemptive.
Challenges of Motivational Interviewing
Motivational interviewing is a process that includes the mastery of key interpersonal skills. It can be challenging to change coaching styles and attitudes, especially if you feel you are knowledgeable of the benefits of health-promoting behavior and you are anxious to see your client feel better.
Motivational interviewing takes time and practice. If this is a technique you want to use in your coaching practice, it is important to practice and get feedback on your techniques.
Motivational interviewing is a strategy that may be useful in the health coach setting to help coaches understand their clients’ mindset and experience with health. It is important to note, however, that motivational interviewing strategies should never discount the importance of acknowledging, weighing, and helping clients navigate the social determinants of health and other factors that influence health and decision making.
If you want to learn more about the science of health behavior change and the social determinants of health, we invite you to read these articles:
- Health Behavior Science and Why It’s Important for Health Coaches
- Behavior Change vs. Mindset Change: Using Design Thinking to Develop Healthy Habits That Stick