Watch a 60-minute TV interview (example: Dr. Phil)?in your discussion discuss all of the following: What stage of change do you believe the client(s) is/are at? (You will need to re

Tell me about a problem you solved at work and how you solved it." Describe how you made an important decision at work."

Questions that should not be asked Certain subjects can be the basis for complaints of discrimination on the basis of e.color, gender, marital status, national origin, religion, age, and disability. For race

reason, the following questions are examples of ones that should be avoided in reemployment interviews. If the questions are not job related, do not ask. 1"What is your nationality and native language?" "Place of birth?" 2. What is your religious affiliation?"

3.What is your marital status? Spouse's name?" "What is your maiden name?

a Where does your spouse work?" "What does he/she think of your working?"

5.Do you have a family or plans to start one?" "Who will baby-sit for you?" 6.What is your date of birth?" "Date of graduation from school?" "Age?"

Box 3-2 (continued)

Using Questions Questions play a major role in interviews as tools of the trade. The wording of questions is as important as one's manner and tone of voice. A friendly approach in asking the questions communicates the desire to understand and be of assistance. The kind of questions asked should require the other person to talk 60% to 70% of the time. Questions that are highly specific or may be answered with one word, such as "yes or "no, " should be avoided

initially, but may be necessary to follow up on specific information. A SKIlled person listens and evaluates each answer and may probe further

Questions may be classified in several ways: open or closed, primary Or secondary, probing, and neutral or leading.

Open and Closed Questions pen questions are broad and give the interviewee great freedom in deciding wnat lacts, thoughts, and feelings to express while giving the protessional

an opportunity to listen and observe. Open questions allow people to tell neir story28 The following are examples of open questions:

Will you tell me a little about yourself? What are some foods you like to eat during the day? What have you done in the past to try to lose weight?"

wnat made you decide to seek employment here?

66

1/COMMUNICATiON SKILLS

At the beginning of an interview, open

questions are less thre

communicate

more interest

and trust; answers reveal what th:hing

ter amount of ti

hreate al what the interviewt

thinks is most important. time the Disadvantages

are that they may involve a greate amount e

isorganizeda collection of unnecessary

information, and lengthy, disorganized

restrictiong- a

The following are examples of open questions with moderate ree

"Can you tell me about the types of meals you eat during the daa

"What did the doctor tell you about your health and diet?

"What were your job responsibilities in your previous position?"

"How did you become interested in this position?"

"What skills do you have that are important for this job?"

CASE ANALYSIS 6

What topics would you like to discuss with Mrs. Maynard about controlling her blood

pressure?

In follow-up visits, open questions should be broad to allow the dlient

to determine the focus of the interview. Examples are, "How are dietary goals progressing?" or "What progress have you made sine

last talked?" The counselor should begin discussion with whatever b current concern to the client. For opening questions, the interviewer sho

rer to the records regarding the client's background, problems

previous counseling goals. Closed questions are more restrictive; that is, they control the len

answers while obtaining a single fact or missing information. questions are more limiting than others, such as:

and

ngth ot

ome closed

"Who cooks the food at home?" "Do you salt your food?" Tell me about any snacks you eat between meals. "What special diet or food restrictions, if any, do you folloW

Closed questions give the interviewer more control, requ ralue w from the interviewee, and are less time consuming which is only a short screening is needed.3 Disadvantages include the ws l of communication, which might result if the interviewe . interest in the answers, and the need for additional questio ewer

shows li"

Ue when

brain

information. Table 3-2 summarizes the advantages ana d the different kinds of questions.

ntages o

3/INTERVIEWING 67

Advantages Type of Questions

Disadvantages Gives interviewee control

Open Time consuming

Communicates trust/interest Supplies unneeded information

Less threatening

Tells what the person thinks is important

Gives interviewer control Closed Provides incomplete answers

Provides quick answers Short answers force more questions

Verifies information

Primary Introduces new topics

Secondary Elicits further information

Leading Directs person's answer

Reveals bias of interviewer

Neutral More accurate answers

Table 3-2 Advantages and Disadvantages of Questions

Primary and Secondary Questions

Questions may also be classified as primary or secondary. Primary ques- tions or requests are used to introduce topics or new areas of discussion. The following are examples:

Now that we have discussed your most recent position, please tell me about your former job with Smith & Company"

"Now that we have discussed the foods you eat at home, please tell me about what you eat when you go to restaurants."

Note that mentioning what was just said shows that you have been listening. Secondary questions, also referred to as "follow-up" questions, are

equests to obtain further information or explanation that primary ques- ions have failed to elicit. Interviewees may have given an inadequate

esponse for many reasons, including poor memory, misunderstanding of the question or amount of detail needed, and the feeling that the question s too personal or irrelevant. Specific follow-up questions, such as the

following, may be asked: What do you have for dessert?

68 1/COMMUNICATION SKILLS

"What other

beverages do you

drink?"

"In your previous

position, how many

pe0ple did you supervic.

nprowe Although the client may not be able to answer the precedine auso.

week the spur of the moment, short-term memory

of foods can be in d of the day of the

questions Probing

ala with some prompting.

The client may be reminded of the dav ofPrO

where he or she spent the day, whether meals were eaten

restaurant, whether others were present, and so on.

Probing questions are secondary questions that ask clients to.

partial responses or to continue."° For example:

"Could you elaborate on. . .

"Will you tell me more about. . .

Neutral and Leading Questions Neutral questions are preferred to leading questions. Neutral question allow the respondent to decide the answer, whereas leading questions direc

the respondent toward one answer, an effect that may be unintentional

on the part of an inexperienced interviewer" Leading questions suges an expected answer, as in the following examples:

"You drink milk, don't you?" "Yes, of course." Instead, ask: "What beve ages do you drink?"

YOu aren't going to eat desserts anymore, are you?" "No." Instead as "What will you have for dessert?"

"Breakfast is SO important. What do you have? Cereal?" Instead ask: "What do you have to eat and drink first after you wake up in u morning?"

One of these questions assumes the client eats breakfast, and i these

instances people may answer even if they usually omit the meal. hi Clients

may change their answers on the basis of a nonverbal appearance of the

practitioner of surprise, disgust, dislike, or disagreement with what clients

are saying. To receive uninhibIle

responses from clients, tn terviewer needs to avoid n appearances.

Discussing interview information Source: Photo by Joe Mitchel.

SELF-ASSESSMENT 2 Directions: ldentify the following questions as open, closed, pri-mary, secondary, or leading

VOu mentioned that the only meal you eat at home is dinner. Can you tell me uhere you eat your breakfast and lunch and what you are likely to have?" "Do you put mustard on your hamburger?"

3. "What do you put on your salad?" 4. "How do you cook your meats?"

Directives

When you as the interviewer sense that too many questions are being asked and the respondent may be developing a feeling of interrogation, you may introduce some questions as a statement or directive. For example: "How has your diet been going? may be changed to "Td be interested in hearing how your diet has been going." "How did you become interested in this position?" may be changed to "Td be interested in some of the reasons you decided to apply for this position." This makes the interview more conversational. Questions should be asked one at a time and the interviewer should concentrate on listening carefully to the answers rather than thinking ahead to the next question.

Sequencing Questions Questions can be arranged in a "funnel," "inverted funnel," or "tunnel" sequence. A funnel sequence begins with broad, open questions and pro-ceeds to more restrictive or closed ones.340 The funnel sequence is a series of questions, each covering a different topic to gain specific information. It may be an appropriate choice in a nutrition interview.

EXAMPLE "Please tell me about the foods you eat during a day's time." "What do you have for snacks between meals?" "We haven't discussed beverages-what do you like to drink?"

Beginning the interview with open-ended questions poses the least threat to the person and encourages a response. The person then volun-

Eers information, making it unnecessary to ask additional questions. An

Verted funnel sequence may be preferable. In preemployment interviews,

xample, an apprehensive applicant may feel more comfortable initially

uealing with a specific closed question than with a broad, open one, such

70 1/COMMUNICATION SKILLS

as "Tell me about yourselt." As the meeting progresses.

become more open." 26

questions n ments star

with

In "What"

takinga or

food

"Tell

and

me

nutrition

about" elicit

history, better

questions

responses

or

that

statem.

than

do "Do not

you requi

an

Review dict history examples in Box 3-1. Questions that

"yes" do nYou

or no sufficient answer or may be answered with one word or "ves

less productive, as in the following examples:

EXAMPLE "Do you eat breakfast?" "Yes."

"Do you like milk?" "No."

"How often do you eat meat?" "Every day."

A series of short, sequential, dead-end questions from the profession ional list of information to be gathered prevents people from telling their e and information may be omitted as a result. Instead, gather this infam tion using a broad opening question or directives, as follows:

EXAMPLE "Please tell me about the first foods and drinks you have most days, what you eat, and the amount."

Why" Questions Some recommend avoiding questions beginning with why. "Why indicate one's disapproval, displeasure, or mistrust, thus provoking fensive feelings, as it appears to ask the person to justify or explain ns her behavior. For example:

"Why don't you follow your diet more closely?" "Why don't you eat breakfast?" "Why don't you exercise more often?" "Why did you resign from your job?"

Clients may react defensively or explain their behavior in a ma believe is acceptable. rthe

"I don't follow my diet because I don't like it. You wouldn't k "I can eat breakfast if you think I should." "I don't exercise because I don't have time. Do you exercise e?" "I resigned because there was no chance for advancement. t. If threatened by a "why" question and unwilling to reveal tne isg

uth

reveal the ans individual may answer in an evasive manner, in which case nou* thing is g

5/STAGES AND PROCEsSES OF HEALTH BEHAVIOR CHANGE 113

intervention should increase the effectiveness, assist the client in progress-ing to the next SOC because of enhanced motivation and readiness, and reduce the likelihood of dropping out of treatment because the intervention was not appropriate.

Stages of Change Change is not viewed as a single event, such as "I will eat less sodium start ing today,

"

but as an unfolding process over time requiring more than one attempt. The model in Table5-1 shows the how, not the why, people change either with counseling or without it on their own. To make changes, people progress through six identified stages. The tasks at each stage vary, and movement through the stages represents personal progress for the client.

Precontemplation

In stage 1, Precontemplation, a person is unaware or underaware that a health problem exists, denies that there is a problem, or has no intention to take action to change. Thus, the individual has no plans, for example, to modify eating practices to lose weight or start exercising in the next 6 months.34 The person may have tried a change previously and failed, such as to lose weight, and may be resistant to the health professional's efforts to suggest possible changes. Perhaps a visit to the doctor initiated a referral to see the nutrition and dietetics counselor for weight loss, even if the patient was not concerned with his or her weight.

Because these clients are unaware, uninformed, or unconcerned about the health problem, the counselor needs to assess the client's views on making a change and address the reasons for not wanting to change rather than providing dietary information. Educating the client about food changes not appropriate at this stage. To identify this stage, the counselor may

asAre you seriously intending to change (name the problem behavior) in the next 6 months?"

1. Precontemplation No intention of changing in the next 6 mno.

2. Contemplation Intending to change, but not soon.

3. Preparation Small changes are made, intending to change in 30 d.

4. Action Changes are made in food choices regularly.

5. Maintenance Behavior changes maintained for 6 mo.

6. Termination

Occurs only if changes are maintained for a year or more.

Tahl

2/COUNSELING FOR HEALTH

BEHAViOR CHANGE

-fat diet ande Cotoa 114

less fat (or more fruits and vegetables) in the near futur2DOUl e

Droblem andi a person with a heart problem may need to know the health benelits

this.

The client needs to "own or acknowledge the health i

For people ignoring the relationship between a high-fat :

ght about eatin heart disease, for example, one may ask: "Have you tho

re" and

At this stag change as well as the risks of not addressing the problem Denef

ofene negative aspects."** These individuals are not ready for act and

idensith interventions. Knowing the person' s SOC helps the counelene

the appropriate type of intervention. Table 5-2 lists sample questions deng interventions at each stage.

Intervention Question for Client Stage

Consciousness raising Precontemplation "What can I do to help?"

Assess knowledge "Do you ever read articles ." about.

Increase self-awareness, gie "What do you know about the relationship between. .. written and oral information

Assess values, beliefs "Does anyone in your family have this problem?"

"Are you aware of the Cognitive restructuring Consequences?"

"How do you feel about making Discuss risks and benefits a change?"

Contemplation "What changes have you been thinking about?" Assess knowledge "What are the pros and cons?" Assess values, beliefs "How do you feel about it?" Assess thoughts, feelings "What would make it easier or Increase pros, decrease

barriers harder?" "What would be the results of the change?"

Self-evaluation "How can I help? Preparation

Cognitive restructurin "Are you intending to act in the next 1-6 mo?" Self-efficacy, commitment "How will you do it?" Decision making "What changes have you made already?" Discuss beliefs about au

billty

"How will your life be imprmin Table 5 2 Stages of Changa l

115 ANGE

"What are you doing Action

differently? Stimulus control "What problems are you having?" Self-reinforcement

"Who can help you?" Social support "How can I help?" Self-management "What do you do instead of Goal setting, group sessions, self-monitoring, relapse prevention

(former behavior)?"

"How do you handle times Maintenance

Coping responses when you slip up?" "What obstacles are you Relapse prevention facing?"

"What are your future plans?" Self-management "What issues have you Commitment, goal setting, solved?"

control environment

Self-management, self-efficacy

Termination

Table 5-2 (continued)

Contemplation In stage 2, Contemplation, a person is aware that the health problem exists

and intends to do better eventually, such as eating differently or exercising more. He or she has no serious thought of or commitment to making a change, however, and keeps putting it off."" The person may be mentally

Sruggling with the amount of time, energy, effort, and cost of overcoming a nealth problem or may be discouraged by previous failures. When the

Cons of changing a behavior are large and the pros are small, the result

dy De ambivalence that keeps people stuck at this stage tor long periods

OT ime, even months or years." The person needs to make a decision.

The counselor may ask, for example:

What have you been thinking about in terms of making a change?"

What are the pros and cons of doing it?

How can you change your environment?

what do you think about eating less fat? What are the barriers or ob

stacles to doing it?"

116 2/COUNSELING FOR HEALTH

BEHAVIOR CHANGE

Preparation

In stage 3, Preparation, a person is more determined to make a

ut 30 days. a chang ant

e or she intends to take initial action soon, perhaps in about 30 davs

may report small changes in addressing the problem behavior, h

reading a few food labels or buying low-lat foods. Clients neod,uch

lop a plan o make

commitment to change, set priorities or goals, and develonMak

action3

The counselor may inquire about possible interest in losimo

becoming more physically active, making healthier choices. and losing weighu records of food intakes. A study of parents of obese children ng weight loss found that about 62% of parents were in the action needing

SOC for child dietary behaviors, but only 41°6 were tor physical activi

child behaviors. Parents who thought their own weight wa

en's problem were less likely to make changes in their overweight chilten

behaviors.

Action

In stage 4, Action, a person takes action to implement a plan and onee come the health problem by actively noditying food choices, behavion environments, and expeticnes 'keep in mind that most clients are mor in the action stage when first teferted for counseling. leople are classified in this stage if they have altered a behavior successtully tor a certain period or up to 6 months, such as purchasing ditlerent groceries or exercising three times a week

Considerable comnmitment of time and energy is required in the action stage when people are trying to change.' The counselor may ask: "What are you doing differently already?" At this stage, clients need knowledg and skills and should know how to respond to a lapse or relapse. New behaviors are not firmly established in a week or a month, and old pa terns may resurtace.

With overweight adults usingTTM with SOC, there was some evide In an intervention that there were improvements in dietary habits d

ne

in physical activity. Ex amples were increased

exercise frequency an duration, increased tr

and vegetable consu tion, and reduced dielu fat intake.

The counselor deveiops

relationship with the cie

5/STAGES AND PROCESSES OF HEALTH BEHAVIOR CHANGE 117

2 CASE ANALYSIS

What SOC is Mr. Howard in?

Maintenance

In stage 5, Maintenance, a person consolidates and integrates new health

behaviors into his or her lifestyle made over several months. With time,

new behaviors need to become automatic. The client has to maintain the

new, healthier habits and work to prevent relapse.7 Maintaining weight loss, for example, takes continuing effort. For some people, this stage

continues for months, years, or a lifetime, or until the behavior becomes a pattern and is incorporated into one's lifestyle. The counselor may ask:

"How do you handle small lapses?" Additional information on counseling about lapses and relapse is found in Chapter 8.

Termination The ultimate goal is the Termination stage, in which changes have been maintained for years. The termination of a behavioral problem occurs if the client reacts automatically, is no longer tempted by the former

behavior, and is no longer lapsing or relapsing. Some people never Teach this stage, but periodically struggle with the health problem. In situations like weight control, a lifetime of maintenance may be the realistic goal.

Recycling Most people do not maintain changes in behaviors successfully on the first attempt. How long do your New Year's Eve resolutions last, or example? Prochaska proposed that most people proceed through the stages in a spiral, rather than a linear fashion. Because lapses and elapse are common problenms, recycling to an earlier stage, such as rom action back to preparation or from preparation back to contem- plation, may be expected several times as people struggle to modify or cease behaviors."

People may avoid high-fat and fried foods, for example, and then start aung them again. Moving back and forth through the stages represents a earning process for the client. Lapse and relapse and the negative emotional eactions (guilt, shame, failure) that may result are discussed along with he skills to recover in Chapter 8. People can learn from their mistakes with the help of the counselor and continue trying