“Motivation” is a word that Dympna Pearson uses a lot, but her idea of motivational talk is the opposite of what the word usually implies. It is not about running on stage in a cloud of dry ice and bombast and hectoring people into submission. Most of what Pearson does—and teaches others to do—involves either remaining silent or quietly paraphrasing back to people what they have just said: “reflective listening.” She is a big
fan of
a 1991 book called
Motivational Interviewing,
by William Miller and Stephen Rollnick, though she had already worked out much of her basic approach when she first read it. Miller and Rollnick developed “MI” in the 1980s as a way of helping people with problem drinking. Miller, who was treating and researching alcoholism at the University of New Mexico, decided to collect data on which patients were recovering the best. He was surprised to find that he could attribute two-thirds of the variation in how well alcoholics had recovered six months after treatment to “how well their counsellor had listened to them.” The clients who worked with the most “empathic” therapist all succeeded in managing their addiction, whereas only a quarter of those working with the least empathic counselor got better. Talk of empathy is not touchy-feely in this context. It can be the difference between kill and cure.
By the time someone reaches a dietician for weight loss, they are often in a state of defensiveness and despair. They may feel that they have “tried everything,” for years if not decades, and that nothing can or will make a difference. Some claim they do not actually want to change: they say they like their comfort foods too much, they are too busy to exercise, and anyway, they only came along because the doctor told them they had to. In this state, advice is the last thing that will help. Although it may sound counterintuitive, Pearson’s approach involves “rolling with the punches.” Instead of arguing and telling someone that they are wrong to eat such a bad diet—which will only create more hostility—you say something like, “Oh, so it seems as if it’s hard for you to eat healthily right now,” or, “Would you say you are pushed for time to exercise?” It doesn’t matter if there are pauses, because that shows that the dietician is giving the other person time to reflect.
As the conversation continues, maybe you ask them how important they feel it is to change. This is the point where Pearson gets very excited. If she hears the merest inkling of an intention to change, she echoes it back at the client. It might be nothing more than saying something like, “Maybe I do need to lose weight,” or, “I would quite like to get my diabetes under control,” or, “I wish my children ate better.” To Pearson, such statements are golden, because they signal an intention, however slight, to try something different. “We let this change talk fly away, we miss it all
the time,” she says. But if a counselor can only hear it and repeat it back, the patient—just maybe—will see that he or she, and not the health professional, is the person who is calling out for change. “It brings a smile to my face when I hear them soften and say, ‘Well, I suppose I could . . .’”
We are all ambivalent about change. Faced with a particularly tempting platter of freshly baked cookies, we may feel a bit like Zerlina in Mozart’s opera
Don Giovanni
, who struggles—unsuccessfully—not to be seduced while singing the line, “
Vorrei e non vorrei
”: I want to and I don’t want to. A person can passionately want to lose weight but equally passionately desire the comfort of a soft pillowy hamburger with all the extras. It would be dishonest to pretend that there are no downsides to eating slightly less than you could every single day. But the part of us that wants
not
to eat the hamburger or the plate of cookies is also real. When a dietician hears the first inklings of “change talk,” says Pearson, he should not hurry the person on to the practicalities of dieting or an exercise program, but try to capture the desire for change in such a way that the patient can hear what she has said. The dietician’s job is not to persuade, but to strengthen someone’s own desire for change. At first, a client might say, “I want to, but I can’t.” Or, “I know I should,” which still has a tentative air to it. If the dietician can wait patiently enough, the person may nudge herself out of her own ambivalence. Pearson sees her task as enabling someone to move from saying, “I want to,” or “I should,” to “I will.” This, to her, is the most powerful phrase, because it signals a firm intention rather than just a vague inclination.
Pearson knows that this approach can sound “touchy-feely.” But in her own mind it is simply good, evidence-based medicine. In fact, although there is as yet no conclusive evidence that motivational interviewing is the best way to enable dietary change, the indicators are encouraging. Four controlled randomized studies found that sessions of MI made people more likely to stick with a diet program—whatever the program might be—than conventional dieting interventions alone involving advice, information, and cognitive training in how to change behavior. The signs are that MI can help people to maintain new eating behaviors long enough for them to become habitual. In one study, 148 obese women were all given a year of intensive diet treatment. Each of
them participated in eighteen group sessions aimed at giving them the skills and information to make major dietary change. Half of them also received just three sessions of individual MI with a dietician. A year on, the women randomly assigned to the MI group had lost 2.6 percent more body fat than the others.
A small 2014 trial also found that motivational interviewing helped obese and overweight children lower their BMI. Trials involving addiction rather than diet, however, have been mixed, with motivational interviewing proving more effective in some clinics than in others. Miller and Rollnick put this down to “differences in clinician skill in delivering MI.”
What is starkly clear is just how ineffective the old advice-giving is. As one article on MI says: “Confronting clients can lead to defensiveness, rapport breakage and, ultimately, poor outcomes.” When you hear Dympna Pearson modeling what the standard advice-giving conversation sounds like, it becomes obvious that—however good the intentions—this kind of talk will do no good at all. “The essence of it is how you are with people,” she says. Several times, I saw Pearson do role-playing exercises to demonstrate how easy it can be to slip into an unproductive conversation about change. To show other counselors what is not effective, she keeps jumping in with “helpful” pointers and talks more than she listens, with a very slight sharpness in her voice. Even though it is only role-play, you can hear the other person getting defensive and annoyed. It is painful to watch. It reminded me of the futile conversations I frequently have with my teenager, the ones where I confront him about not leaving his socks on the floor or clearing out his lunchbox; in these exchanges, nothing is achieved, except that both of us are left in a slightly worse mood than before. The more someone is pushed, the more he comes up with reasons why he can’t or won’t change.
It is a truism that no one can make someone else change. “We shouldn’t shove people into the swimming pool,” says Pearson, “when they’re not ready to get in.” Changing our diets always involves losses as well as gains. The water is cold when you first dip a toe in the pool. Giving up junk food involves a separation from some of your fondest childhood memories. Learning to like new foods can feel like leaving your old self behind. Re
covering from an eating disorder entails giving up long-established coping mechanisms. Making yourself try foods that you find disgusting is, well, disgusting. The best anyone can do from the outside is help a person get past their own ambivalence. If Dympna Pearson is right, the hardest part, after so many false starts and wrong turns, after all the failed diets and half-watched exercise videos, after all the stigma and the shame, after all the times you’ve told yourself that this diet would be different and all the times that it wasn’t, is finding the motivation to get back in the pool and stay there long enough that you get acclimatized.
Most public health campaigns aimed at changing diets are
based on the idea that, once we are made to see that certain foods and behaviors are unhealthy, we will give them up. The evidence, however, shows that change in diet does not work like this. Whether you are a dietician sitting in a room with a diabetic patient or a government tackling an “obesity crisis,” persuasion does not cut it, because this is not how we learn to eat. At a social level, the key to improving diet is not pushing people to do something they are resistant to doing, but removing the barriers to change. These barriers could be psychological, cultural, or economic, or they may have something to do with the environment in which we live. Sometimes our whole food system looks like a giant barrier to change, teaching us every day that it is normal to eat vast amounts of sugar and filling our heads with advertising images of beautiful, healthy people eating unhealthy food. We speak of helping people to make better food choices, but in many modern food stores, choosing healthy foods involves ignoring nine-tenths of what is on display.
It looks as if changes in people’s diets that last often come about through “seamless change,” that is, change that happens without conscious effort. Examples of seamless change would be automatically buying more of something when the price comes down, or unwittingly consuming different ingredients when manufacturers reformulate their products. From 2003 to 2010, the average salt intake in Britain fell by 15 percent, not through individual choice, but because food companies cut the amount of sodium in their products under pressure from lobbying groups
and the government: a very benign form of seamless change. The trouble is that most seamless change makes us eat less healthily rather than more so. Croissants start to slip into your mouth every day, as if by accident, because you get a new job where they are laid out with the coffee. Or you don’t notice that the glass of white wine you always order is now much bigger and considerably more alcoholic than its equivalent a decade ago. A 2008 study of more than four hundred people in the United Kingdom found that around 40 percent were eating more takeouts and ready-to-eat meals than they did during childhood, but most could not say why: “The change just happened.” By contrast, when someone tries to make conscious changes to eat more healthily, their path may be lined with hindrances.
Let’s say you resolve to eat more fresh vegetables and fruits every day. You may never get beyond the planning and expense involved in shopping for them. One study found that resolutions to eat more bananas often collapsed at the first hurdle because there were no bananas in the house. Even assuming you manage to lay your hands on a supply of fresh produce, there’s the question of how to cook it. Among a sample of low-income families in Chicago, the ones who ate the fewest home-cooked meals were those who lacked the most basic kitchen equipment, such as chopping boards, peelers, and whisks. And whether you have these items or not, you may not have much idea how to use them. Your plans to eat a wider range of vegetables may also be confounded by other family members who complain that they do not like them, in which case, do you cook yourself a separate meal, or do you cook the disliked foods for everyone and risk more complaints, as well as having to throw good food away?
Culture is another barrier. As we’ve seen, traditional wisdom about feeding frequently clashes with the realities of our new food supply. In Britain, South Asians—from India, Bangladesh, and Pakistan, for example—make up the largest ethnic minority, and they are also statistically the ones with the greatest risk of heart disease and diabetes. Research has shown that among British Asians, there are multiple obstacles to engaging in healthier behavior. Among the older generation, especially, there may be a fatalistic attitude toward illness: the view is that diabetes has
been caused by fate, or Allah, or the dreadful British climate, so nothing can be done. Exercise in a gym is viewed by some Muslim Asians as individualistic and selfish; it may be problematic for women, in particular, given cultural expectations in many families that they should not sweat, or be seen to hurry, or wear sports clothes. As for food, the notion of eating smaller portions and limiting rich foods is antithetical to beliefs about hospitality. “Indian sweets are supposedly for special occasions,” says Baldeesh Rai, a dietician who works with South Asian communities, “but in an Asian household, anything can be a special occasion.” Rai has found that in many South Asian families, it is possible to change diets only if the cook of the family—often the mother-in-law—is involved. It doesn’t matter how much information you have on the calorie content of ghee if you are not the one measuring it out.
If you spend too long thinking about all the barriers to change, it’s easy to endorse the common view that almost no one really succeeds in long-term weight loss. You may start to feel hopeless about your chances of sticking to a diet, if that is what you are trying to do. The general opinion is that you might be able to shed a few pounds in the short term, but you will put it all back on again later, with interest, and be worse off than you were before. Anyone with weight issues—or so the thinking goes—is fated to grapple with them for a whole lifetime, without much possibility of improvement. This is a very depressing thought, particularly if you are unlucky enough to have become obese as a child.
Fortunately, it isn’t true. No one could pretend that losing weight and keeping it off is easy, but the evidence suggests that around 20 percent of overweight dieters—one in five—do in fact manage long-term deliberate weight loss, defined as losing at least 10 percent of one’s bodyweight and keeping it off for at least a year. Relatively few studies on weight loss have followed participants for long periods of time, but those that have indicate that a sizable minority do succeed in losing weight without regaining it one year on, and three years on, and even five years on. A little-publicized piece of good news is that, over the past two decades, long-term maintenance of weight loss has improved for those most in need of it. Dr. James Anderson, an endocrinologist at the University of Kentucky, has found that, compared with the 1990s, more of his severely
obese patients are able to maintain a large weight loss, perhaps thanks to the use of more intensive and frequent sessions of behavioral coaching. It has proved possible for some patients who needed to lose more than a hundred pounds—and who might otherwise have been candidates for bariatric surgery—to achieve sustained weight loss (with follow-up after five years) using meal-replacement shakes, carefully managed main courses, and lots of fruits and vegetables, plus regular medical support.