VCU news

By Sathya Achia Abraham

For families across the country, the road to living a healthy lifestyle and shedding extra pounds involves eating right and being active – but the right attitude and a willingness to change are critical factors for success.

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Change can be a touchy subject. In general, people have mixed emotions about making any kind of change – there’s a part of them that wants to, while the other part wants to stay the same.

But according to Melanie K. Bean, Ph.D., a licensed clinical psychologist with the Children’s Hospital of Richmond, a counseling style called motivational interviewing, or MI, can help make the journey toward change more manageable by helping patients explore and resolve their ambivalence about it.

“MI acknowledges that there is that part of a person that does not want to change and that change is really hard,” said Bean, who is an assistant professor of pediatrics in the Division of Pediatric Endocrinology and Metabolism at the Virginia Commonwealth University School of Medicine.

“It helps patients explore those barriers in a way that helps plant the seed toward change, and then the patient is the one who starts to argue for change instead of the clinician trying to advise and push that person toward change,” she said.

Bean works with a unique research program at VCU known as T.E.E.N.S, which stands for Teaching, Encouragement, Exercise, Nutrition and Support, dedicated to helping adolescents between the ages of 11 and 18 lead a healthy lifestyle and manage their weight. The multidisciplinary weight management clinic is the only one of its kind in Central Virginia and includes expertise from across VCU, including from the departments of pediatrics, exercise science, family medicine and psychology.

In 2008, through a grant from the American Cancer Society, Bean began implementing a randomized trial of MI into the T.E.E.N.S. program to see if participation in MI would help improve adherence to the program goals in all three components – nutrition, physical activity and behavior support.

“We’ve found that it’s actually a very respectful and non-confrontational approach that engages adolescents as more of a partner and collaborator and less as a patient recipient role,” said Bean.

Bean describes the MI approach as “disarming,” especially when the clinicians ask the adolescent their thoughts about how they could change and acknowledge that “Hey, you may not want to be here, this is tough.”

“The interaction catches the adolescent off-guard and they listen because it differs from what they may typically experience – where somebody might come in and say here’s the problem and here’s how to change – action that may make a teen more resistant to changing,” she said.

Bean said that clinicians using MI through the T.E.E.N.S. program report that patients respond very well to this approach – that they are engaged and have a platform to talk about how things are progressing. For example, they are able to express what they like about changing and this helps them anticipate the challenges and work through the difficulties.

Moving forward, the research team is hoping to see if using MI in conjunction with the T.E.E.N.S. program will translate to improved physiological outcomes – Body Mass Index (BMI) and other health parameters.

How it works
Thirty-minute MI sessions are conducted individually with the patient and the clinician at two time points. Involving MI early in the treatment process is helpful because it helps patients deal with the early ambivalence about change, so it is done when the teen first begins the program, and then they are given a booster at 10 weeks.

The patient does a Values Card Sort, which is a values clarification exercise in which the teens choose their top five values from a list of 50. The clinician works with them to learn what the value means to the teen, and how the value may relate to the behavior they’re deciding to change. That behavior could involve a nutrition activity or behavior goal.

“The reason we are doing this specific task is to help patients learn that their deeply held goals may be discrepant from their current behaviors. Once they learn that or once it’s highlighted, that can be uncomfortable, and people are more likely to change their behavior than change their value or goal,” said Bean.

“This helps build rapport so discussion can focus on what the patient feels is important and not what the clinician thinks is important. Further, the clinician really helps the patient see connections and can talk the patient through it,” she said.

Together, the clinician and patient map out a plan and set goals they wish to achieve at three months and six months. Patients can discuss any potential barriers preventing them from reaching their goals and discuss ways that will them achieve their goals.

For example, family may be an important value for the patient. The patient can relate the importance of family and may indicate that they want to make a change so that they can be there for their family. They may also recognize that failure to change their eating or exercise habits may contribute to poor health in the future. If they recognize that their family really wants them to succeed, the patient may not be willing to let them down – and hence, may do more to work toward change.

“MI is part of a treatment approach, not the only treatment approach, and it is not a stand-alone intervention. While it is useful to help increase a child or teen’s internal motivation to change, and engage them as a partner and participant in their own change – once you get them motivated, you do need a program – a multidisciplinary approach is needed,” said Bean.

Down the road, Bean said that it could be beneficial to integrate MI into all aspects of the T.E.E.N.S. program so that, for example, dieticians or exercise physiologists could use the approach to help these teens make further progress.