Coach: The health coach is entering the focus stage of the conversation. Her goal is to use the information and concerns she hears from the family to find one area where they want to improve Ethan’s habits.
Health Coach: Okay, so I can see on the questionnaire that Ethan is spending four to five hours a day in front of a screen. We need to talk about reducing that.
Heather: Well some of that time is homework, they have a lot of assignments on the computer for math practice. And he does get to play a few video games, but only after he finishes the homework. Besides, being good at computers will help him get ahead in life. So we want him to get screen time.
Ethan’s Thought: I can't stop playing video games. I wouldn't have anything to talk about at lunch.
Coach: The Health Coach tried to direct Heather toward a topic, which provoked some serious resistance. The Health Coach should ask her what changes, if any, might make sense.
Health Coach: I know it could be hard to reduce screen time, but the American Academy of Pediatrics recommends no more than two hours a day. That means he really needs to cut out two to three hours a day, or it could affect his health.
Heather: I think he's doing just fine. Is that all you wanted to talk about? Because I don't, I don't think it's really a problem.
Coach: The health coach’s argument is only increasing Heather's resistance. A less confrontational approach would work better.
Health Coach: One thing we need to talk about is making sure Ethan gets enough physical activity each day.
Heather: So what am I supposed to do, put him on a treadmill?
Health Coach: Oh, no, nothing like that, but if he could just play outside for an hour a day, or ride his bike, or something like that, that would be fine.
Heather: Well, I don't know about that. By the time we get home it's usually dark out, so I'd rather have him in the house, where I know he's safe.
Health Coach: Well, then, maybe we could talk about another area to make changes.
Coach: Notice how the Health Coach encountered resistance when she tried to dictate the topic of discussion? It might save her a lot of time and effort if she tapped into Heather's insight about what would be reasonable for Ethan. After all, Heather's the real expert on their family.
Health Coach: Let's talk about cutting back on Ethan's soda intake. If we could reduce how much soda he drinks, that could have a real impact on his weight and his health.
Heather: Ask Ethan to cut back on his root beer? I don't think that will go over well. And besides, I don't think that he's drinking more soda than other kids.
Coach: If the health coach listened to Heather's concerns and let her help set the agenda, she might be more willing to hear her out.
Health Coach: I understand you have some concerns about cutting back on soda, but the reason I suggested it is because I think this will be the easiest change for Ethan to make.
Heather: Okay, fine. If you say so.
Heather’s Thought: Just a few more minutes of this lecture and we'll be out of here.
Coach: Maybe if the Health Coach let Heather participate in setting the agenda, she might be more engaged in this discussion.
Coach: The health coach is entering the evoke stage of the conversation. Her goal is to elicit change talk, or speech in favor of change. It’s empowering for the family to voice their own reasons for change, and it can help guide the conversation.
Health Coach: You may not know this, but there's quite a lot of sugar in soft drinks. A 12-ounce soda, like a can of root beer, has 150 calories and 10 teaspoons of sugar. That's why it's a bad idea to keep it in the house.
Heather: Look, I get it. Soda is bad. But I always make sure there are vegetables on his plate at dinner time. Doesn’t that count for anything?
Coach: The health coach’s confrontational tone is making Heather defensive, which will make it difficult to progress to a change plan.
Health Coach: I'm telling you now, Ethan really needs to stop drinking soda, or he'll continue to gain weight and he might develop diabetes.
Heather: Like I said, we’re just big in our family. Ethan might be big for his age, but I think he’s healthy. So what if he’s a little bigger right now? My husband was pretty large when he was Ethan’s age.
Health Coach: Looking at the questionnaire you filled out, it looks like Ethan is drinking a lot of soda.
Heather: He only has, like, two sodas each day. I really don’t think that’s going to hurt him.
Heather’s Thought: The neighbors’ kids drink soda all day long and they’re skinny as rails.
Coach: The Health Coach’s confrontational tone is making Heather defensive, which will make it difficult to agree on a change plan.
Health Coach: So Heather, if Ethan were to keep drinking soda like he is now, what do you think things will be like for him, say five years from now?
Heather: Well, you said he’s pretty healthy right now, right?
Health Coach: Yes, right now he is. But I’m thinking about the long run, and making sure Ethan is in good shape 10, 20, 30 years from now.
Heather: Right. Well, my father has diabetes, and my doctor just told me that I’m prediabetic. So, should I be worried about Ethan?
Health Coach: You’re right. Diabetes does often run in families. And when children stay at this BMI, it significantly increases their risk, so this could be a very real risk for Ethan if he keeps going like he is now.
Heather: Well, I don’t want that for him.
Coach: The health coach is now in the plan stage of the conversation. Her goal is to collaborate with the family to plan realistic change to Ethan’s soda-drinking habits.
Health Coach: So if we're going to make a plan, it's going to need to include Ethan drinking a lot less soda. It's just not healthy for him to have this much. Really, cutting it out completely would be the healthiest option.
Ethan: Are you serious? No soda, ever?
Heather: That does sound a bit extreme.
Health Coach: We’re talking about Ethan’s health, here. You can’t be afraid to make changes that might prevent him from getting diabetes.
Heather: I mean, we can try. I don’t know how it will go over.
Heather’s Thought: This will be a struggle. I don’t know how long I can fight him on this.
Coach: When you dictate a change plan, you run the risk of setting goals that don’t match the client’s motivation and capability. It makes more sense to ask clients what they’re willing to do.
Health Coach: So to summarize, the plan is to cut way back on Ethan's soda, which will help him stay healthy.
Heather: Yeah, we'll see what we can do.
Health Coach: Okay, well, do what you can.
Health Coach: Great. So you'll cut back on the soda and see how it goes. Do what you can. And maybe think about a little more exercise and a little less screen time?
Heather: Yeah. Sure.
Health Coach: Okay. I'd really like Ethan to lose a few pounds by our next visit.
Heather: Oh! Um, okay.
Health Coach: Okay, thanks for coming in. Make your next appointment at the front desk.
Pic 7: The screen fades to black before returning to a close-up of Dr. Schwartz.
Dr. Schwartz: Using motivational interviewing can be pretty difficult at first, but I think the health coach gave it a very good effort. Now let’s look at her dashboard, which will analyze her choices and offer some suggestions for how best to use MI in your practice.
Client Motivation: Overall, the health coach did an adequate job talking to Ethan and his mother about his weight. They will consider making changes to his soda consumption, thought they may not be firmly committed yet.
Feedback on Technique