When a client struggles with change, are our questions part of the problem?
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Issue 37 March 2017

Welcome to Issue 37


 


Warm congratulations are extended to my colleague Eve Reed APD for facilitating such an informative and affirming workshop last week at the Crows Nest Centre. We had a full house share a wonderful day of learning and discussion on the importance of attending to family feeding dynamics when working to improve the nutritional and holistic well-being of children. Eve Reed is Australia's only faculty member of the Satter Institute and Pavestones is proud to facilitate her important work. Feedback from the day reflected Eve's level of skill and knowledge......
 
This course was a fantastic opportunity to zone in further on the DOR (Division of Responsibility) theory and explore the ways in which it can be used and implemented to help all families. It was great to challenge some of the current methods and more conventional advice for working with children. It gave me lots of food for thought!
R.E. APD Attendee

The concept of eating competence has wide arching applications in my practice for both children and adults. Eve provided practical examples and advice for how the DOR can be applied and used. The day was a great update and thorough revision of the Satter approach to developing positive eating habits
J.S. APD Attendee

Pavestones will be continuing to host Eve's work. Watch this space for future announcements. I am looking forward to reporting back on Terrill Bruere's PCOS workshop next issue, it was an excellent PD event. Thanks Terrill!
 


In This Issue


February's Issue 36 introduced the concept of 'change language' and the first steps in working with this important aspect of dialogue with clients. Readers were encouraged to start by simply identifying Change Talk in their clients speech and to simply reflect it and ask for elaboration. You might like a quick recap here. In this issue we will be exploring more about getting Change Talk alive and kicking in session. This vital aspect of client perspective is at the core of the third process of Motivational Interviewing: Evoking.  To skip straight to the editorial click here 

As always if you are short on time, you can fast track down to the summary in the Purple Pavestone Box at the end of the editorial by clicking here...happy reading!

 

Motivational Interviewing 1 

SYDNEY April 6th 


Motivational Interviewing 2

SYDNEY April 7th

There are still places available for MI 2.
If you are keen to continue on from your MI 1 experience, please get in touch by Monday April 3rd to grab a last minute registration


Click HERE for all you need to know about  MI 2 



'Save The Date' for BRISBANE MI 1 & 2

August 17th & 18th 2017


Regos OPEN SOON

 

Thanks for your patience!
The booking portal will be open in April and will be announced in next month's Pavestones.


When a Client 'won't change'
Are you getting what you ask for?

 

I have no special talent. I am only passionately curious.
Albert Einstein

Be careful for what you ask for because you just might get it!
Anonymous

We come to believe that for which we argue
David Rosengren
 

Let's affirm the story we have been building over the last few issues about language and ambivalence:
  • When clients are ambivalent about change they feel two ways about it: 'I know I should...but....' 
  • When we are engaged in attentive listening, these 'two ways' will be identifiable in the thoughts clients share with us in session  
  • Change Talk are statements featuring the reasons FOR change stated by the client
  • Sustain Talk are statements containing the reasons for maintaining the status quo - again as per the client
  • The more Change Talk appearing in a session, the stronger the likelihood of change occurring in the client’s nominated target behaviour
  • Practitioner behaviour directly influences the appearance of Change Talk in session
  • Practitioners can influence a higher likelihood of change in their client by taking responsibility for their behaviour in session.
In Issue 35 we had a look at a core aspect of practitioner behaviour which can influence the appearance of Change Talk & Sustain Talk: managing our urge to tell people what to do. To remind yourself of how unhelpful this ‘best intentions urge’ can be, you can have a quick recap here.

In Issue 36 we explored the importance of listening out for our client’s reasons for change as our very first step in the right direction. The issue capped off by inviting readers to think of typical Change Talk statements heard from clients in session and practise responses that would reinforce these vital aspects of client perspective.

In this issue we will be introducing another key skill to invite more Change Talk from our clients. It is so obvious it seems too simple........just ASK FOR IT!

 


Wise Words from Miller and Rollnick

 

This guidance is insightfully illustrated with this analogy from Motivational Interviewing 3rd Ed (p171):
 
'Perhaps the simplest and most direct way of evoking change talk is to ask for it. Ask open-ended questions for which change talk is the answer. You are, in essence, inviting the pro-change members of the internal committee to speak'
 
Anyone who has worked on a committee with energetic members promoting opposing opinions, knows how planning and decision making can veer off track with rival views jostling for air time. It’s an interesting analogy to imagine ‘passing the mike’ to the committee members that clearly have the best intentions for the most beneficial outcome. This preferencing is not about disallowing the 'anti-change' members, we want to maintain the MI spirit of respect and acceptance, it’s just interesting to pause and consider ‘who’ our questions invite to the podium.
 


What might these evocative questions sound like?


Featured below are four examples of questions that a client would likely respond to with Change Talk but there there would be thousands of questions you could artfully conceive. In this scenario, our client is seeking to overcome years of chronic dieting causing anxiety, social isolation and reactive binge eating.

Each of the sample questions below focuses on a particular kind of Change Talk from the categories represented in DARN. As encouraged last issue – don’t get too wound up in categorising Change Talk if you are relatively new to this concept. This is not essential knowledge to work competently in the Evoking process of MI. 

These questions can be read as a sequence but in real life there would typically be significant exploring and engaging between each question.

Desire (what does your client want, wish, like)
  • You’ve mentioned that your eating has been this way for a long time and it feels kind of familiar. I wonder, could you tell me anything about what you would want to change about your eating at the moment?’
Ability (what does your client think they are able to do or could possibly do)
  • Hmmm. So it’s the anxiety that eating causes you that you would be most keen to improve. You are really feeling its time to move on from all the rules. I’m curious, what have you been able to do to manage anxiety in the past?
Reason (what are your client’s reasons for change)
  • You have practiced some powerful strategies and it sounds like the slow breath exercise is what you get the most benefit from. What would be your best reasons for applying your breathing strategy assist yourself to start introducing some ‘forbidden food’.
Need (what is the client’s urgency or priority for change)
  • You’re excited about meeting a friend for coffee and not googling the menu beforehand. It's liberating to think about that! I am also hearing it feels a little daunting and you want to take it slow. To keep you in the driver’s seat of this process I wonder what needs to happen first for you?


When we ask for NOT changing - FAIL!


It’s not really that we ‘fail’ when we ask questions that promote sustain talk or bias NOT changing in response. Exploring shadows can yield rich and meaningful content in many therapeutic conversations. However, when counselling to assist behaviour change in ambivalent clients, MI would gently caution that we need to be aware of the impact of these questions and to have reasons that are in the client's best interests for asking them. 
 

Here are some examples of questions, based on the scenario above, that may generate a lot of sustain talk, tipping the balance if we are unaware:
  • Why do you have to always stick to the calorie rules?
  • What has prevented you from dealing with this before now?
  • What is so important to you about always sticking to the rules?
  • What are your barriers to changing this? 
The last example on exploring barriers is a really interesting one. Many coaching models feature barrier explorations. The challenge is, if we ask this too early in the Evoking stage it can start to tip the ambivalence back into status quo. During the final Planning stage, when the client is ready to take steps, it may sometimes be fruitful to enquire:
  • 'What are the most likely challenges that may limit your ability to really follow through with what you want to do?'
In my experience, if the client is really in charge of the Planning stage and there has been an effective Evoking stage, these challenges to change will naturally emerge and we don’t have to go hunting for them. If in doubt, leave it out! You can always come back to debriefing challenges at the review session.

In summary,
if you are feeling stuck with a client who is clinging to the status quo in their dialogue with you – perhaps have a listen to what you are asking for. 

 
I have chosen an old personal favourite by Kate Bush for this issue: Cloudbusting. She sings in her iconic style about the power of saying something out loud, exactly what we are relying on in the Evoking stage of MI. Enjoy the gorgeous '80s video styling.
 


Ooh, I just know that something good is going to happen
And I don't know when
But just saying it could even make it happen

Issue 37 Pavestone
Asking Evocative Questions 

 

Nutrition is a science. Eating is a Behaviour. 
Behaviour change is difficult.


 
Using Reflections, Affirmations, Open Questions and Summaries are core skills in Client Centred work fundamental to building trust, engagement and communicating respect The Four Processes of Motivational Interviewing is a framework for using our core client centred skills intentionally to guide our client's conversation about behaviour change in a meaningful, goal focused direction

The Four Processes include Engaging, Focusing, Evoking and Planning
 
Engagement is a dynamic process of building a helpful connection with the client 

Engagement relies on the skills of Active Listening, Affirming, Reflecting and Open Questions and invokes the tone of empathic, warm curiosity
 
Engagement can be limited by specific practitioner behaviours including being 'the expert', conducting a lengthy premature assessment and describing a client in language they disagree with or do not identity with.
 

Moving from Engagement to the next process in MI called Focusing needs to be well timed to avoid the 'Premature Focus Trap'

Focusing is the process by which the practitioner develops and maintains a specific direction or focus in the conversation about change, with the client
 

We may encounter many challenges to finding a focus with our client. This is particularly so when the client may state they are doing 'everything they can' when perhaps that isn't the case.

Client centered, open questions and reflective listening are core skills to assist with focusing challenges.
 


Issue 33
Skillful means may be adopted by the MI practitioner to assist the client choose a useful focus for their conversation about change.

Issue 35
The Righting Reflex can be defined as:
The desire to fix what seems wrong with people and to set them promptly on a better course, relying particularly on directing

Directing and advising ambivalent clients can be counter productive as this typically provokes the client to rehearse out aloud all of their reasons for NOT changing.
 

 Issue 36
Clients' statements about change can be loosely grouped into: 
Change Talk: any client statement that is pro-change &
 Sustain Talk: client statements that are about maintaining the status quo

Identifying Change Talk and responding skillfully is a key step to reinforcing our clients' own motivations for change and is directly correlated to better change outcomes. Working with Change Talk is the core work of the third process in MI: Evoking
 


This Issue 37

More Change Talk can be generated in sessions with clients by skillfully conceiving questions that generate Change Talk in response.

Caution is advised when asking too many questions that generate Sustain Talk from the client who is receiving our assistance for supporting behaviour change.
 


 Suggestions for Reflection  


You are invited to take a few minutes with your reflective practice journal and jot down 5 typical Change Talk statements you might hear your clients say to you in your sessions. You can use the questions from last issue's Reflection Box if you completed that task.

Now try 'working in reverse':
Take a moment to think of an open, evocative question that would generate each Change Talk statement you have nominated, as a response.

 
I'd love to hear your thoughts, curiosities, insights. Please email me to let me know.

Enjoy experimenting!
Keep reflecting!


Tara MacGregor
www.taramacgregor.com.au
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Counselling Skills Training for Health Care Agencies & Hospital Departments


PLAN NOW for 2017


If you are interested in organising training for your staff come on over to the new webpage to learn more and read great feedback. Please email Tara to express your interest for 2017 as inquiries are coming in and the schedule is now booked until June
 

This Issue's Great Read


So pleased to be sharing the work of my dear colleague Laura Kiely APD:


FOODS TO BUILD BRILLIANT, RESILIENT BRAINS


A comprehensive, fad-free look at sound nutrition for the mental well-being of our small people.
 

Affirm Your Knowledge
Online CPD Quiz for APDs


You can turn your dedicated reading of Practice Pavestones into self-assessed CPD hours with on-line convenience using the 2014 & 2015 Quiz.

Learn all about the quiz options available on the dedicated webpage HERE 

Click HERE to access the 2016 Quiz Issue 

'Health Not Diets' Training

 

For all upcoming dates for 2017
follow the link HERE to the Health Not Diets website


Find out about:

The Health at Every Size (HAES) ® movement
The five core components of the non-diet approach
Strategies and worksheets to use with your clients
Evidence base, current research and practice based research potential
How to integrate the non-diet approach into the Nutrition Care Process, including nutrition diagnosis and PESS statement development


Looking for On-Line Convenience?


NEW ON-LINE TRAINING


The Non-Diet Approach for Dietitians online course suits dietitians and nutrition professionals.  It is a self-paced interactive course hosted by Open Learning which uses video, written materials and activities to develop your understanding of the clinical application of the weight-neutral Health at Every Size paradigm.  Participants have 12 months to complete the course, and passing the assessment means you'll get a lovely certificate for your efforts but more importantly fabulous skills for helping your clients. 
More details and the enrollment link can be found here

Eating Disorder Professionals Retreat 


June 30th-July 4th 2017


Suitable for any health professional working with people who feel concerned about their body, food and eating. Dietitians who work in Eating Disorders will find this retreat particularly suitable.

Hosted by  Body Positive Australia (including Fiona from The Mindful Dietitian)

Featuring creative and innovating workshops from some of Australia's most experienced practitioners, as well as yoga, amazing food, great networking opportunities and so much more!

For all information about workshops, rooms, rates etc please click through here 
Please contact Fiona directly fiona@bodypositiveaustralia.com.au with any queries.

 

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Tara MacGregor PACFA Reg. 21520

 BSc MSc H.Nut & Diet. G.Dip Couns

Tara MacGregor is a dual qualified Accredited Practising Dietitian and Counsellor & Psychotherapist in private practice. Graduating from Sydney University in 1991 she has worked in a broad spectrum of clinical areas in public and private hospitals until specialising in disordered eating in 2004. Tara works exclusively in the non-diet paradigm and is a committed teacher and promoter of the Health At Every Size (R) philosophy. Tara is a PACFA Accredited Supervisor, Member of the Motivational Interviewing Network of Trainers (MINT) and author of The Essential Counselling Skills for Dietitians Workshop. Tara provides skills training and mentoring in the form of clinical supervision for Health Professionals and enjoys tremendously the exciting opportunities, insights and growth this offers both herself and supervisees. 

Make an enquiry about supervision and mentoring with Tara.

Suite 3, 780a Pacific Highway Gordon NSW 2072
M 0459 991 788
www.taramacgregor.com.au
www.taramacgregor.com.au
tara@taramacgregor.com.au
tara@taramacgregor.com.au
Copyright © 2017 Tara MacGregor, All rights reserved.


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