Person-Centred Motivational Interviewing in Obesity Care

Points clés à retenir

Motivational Interviewing in Obesity Care

Motivational interviewing (MI) is a collaborative, person-centred communication approach that supports people living with obesity to explore ambivalence, strengthen intrinsic motivation, and engage in care without blame or judgement. In obesity management, MI helps counter weight stigma, build therapeutic alliance, and support long-term engagement in a chronic disease context.

Core Principles and Mechanisms

MI is grounded in empathy, partnership, and respect for autonomy. Rather than persuading or directing behaviour, clinicians use reflective listening, open-ended questions, and affirmation to elicit a person’s own goals and values. This approach recognises obesity as a complex, chronic disease influenced by biological, psychological, and social factors, rather than a simple issue of “motivation” or willpower.

Language, Stigma, and Clinical Communication

Commonly used terms (e.g. “motivation”, “compliance”, “lifestyle failure”) can unintentionally reinforce stigma and disengagement. MI encourages neutral, non-judgemental language and avoids assumptions about readiness or responsibility. Small shifts in wording can meaningfully improve trust, disclosure, and shared decision-making.

Applying MI in Clinical Practice

MI can be integrated into routine obesity care without requiring long consultations. Brief MI-consistent techniques include:

• Asking permission before giving advice
• Reflecting ambivalence rather than correcting it
• Exploring what matters to the person, beyond weight outcomes
• Supporting self-efficacy through achievable, person-defined goals

MI is applicable across treatment pathways, including behavioural support, pharmacotherapy, and bariatric surgery, and is most effective when embedded within multidisciplinary care.

Orientations futures et prochaines étapes

• Embed MI training within multidisciplinary obesity care teams
• Align clinical language with person-first, non-stigmatising principles
• Evaluate MI outcomes beyond weight, including engagement and patient experience
• Integrate MI approaches into obesity management pathways

Les résumés sont générés par l'IA à partir des transcriptions des réunions.

Les transcriptions sont générées automatiquement. Si vous remarquez une erreur, veuillez envoyer un e-mail à enquiries@easo.org

Professor Jason Halford • 00:00
Good morning everybody and welcome to the EASO Coms Weathered World person-centered motivational interviewing in obesity care. My name’s Professor Jason Halford, I am the lead for the EASO Psychology, Behaviour and Mental Health Working Group and this is very much within our remit and our area of interest. I’d like to welcome you to this month’s EASO Collaborating Centres for Obesity Management webinar, which this is, and thank you for joining. Now, this webinar will comprise of two 20-minute presentations, one from Jimena and one from Violetta, and then we’ll open it to Q&A. Please use the Q&A tab at the bottom to ask questions, and I will field them to the speakers. This is a recorded session, and it will be available after the meeting. It will be put up on the ASO website. The purpose of these is to share knowledge and expertise across the ASO comms network and to enhance obesity management and patient care. And we encourage attendees to share the webinars with colleagues as well. I will also remind you, could you please complete the anonymous feedback. and those comments we get in anonymous feedback are vital. And it might just be worth mentioning now before we carry on that also we have our Eco in Istanbul in May, and we’d encourage everybody to attend. We’ve got some excellent behavior and psychology and mental health related seminars. Now, I’ve spoken enough already, so I’m now going to hand over to our first speaker, Dr. Ximena Ramos-Salas, who’s going to talk to us about reducing weight stigma through person-centered communication. Over to you, Ximena.

Dr. Ximena Ramos Salas • 02:14
Thank you very much for that introduction, Jason. Can you hear me okay? Yes. You can hear me?

Professor Jason Halford • 02:23
Yes, we can hear you. Sorry, I was on mute.

Dr. Ximena Ramos Salas • 02:24
Perfect. I might turn off my camera if the internet cuts off, but thank you again for that introduction and welcome everybody to this EASO webinar. My first presentation is going to focus on how we can reduce weight stigma through person-centered communication, as Jason mentioned. Here are my disclosures. I am chair of Bias 180, a non-profit global organization with a mandate to address weight bias and stigma and discrimination, as well as other chronic disease stigma related behaviors. I have some grants from the Canadian government and I’m also an independent consultant for several organizations, including the European Association for the Study of Obesity. So Bias 180, just to quickly let you know about it, is a global non-profit organization that is trying to overcome bias, stigma, and discrimination in chronic disease. And as we all know, obesity is a serious non-cumulative disease. And we know that people who live with obesity often live with multiple chronic diseases. And often many of those chronic diseases are stigmatized. So it’s not just obesity that is stigmatized, but many other complications related to obesity are also stigmatized. So we understand from our perspective that people living with chronic illness report a variety of forms of experience stigma in their daily lives, including within the healthcare setting. And that’s what we’re trying to address. So today we’re gonna focus specifically on weight stigma. And let’s start by defining some of these concepts. And first we’ll start with the concept of weight bias, which refers to our own negative attitudes and beliefs about weight. And these can be explicit weight bias, implicit weight bias, or internalized weight bias. And the difference between these is quite simple. Explicit is when we have overt or direct negative attitudes and beliefs about weight and about people with a higher weight. Implicit means that these weight bias attitudes and beliefs are unconscious. So we are not aware that we have these negative attitudes and beliefs. And internalized is when people who adopt some of these negative attitudes and beliefs and apply those negative attitudes and beliefs towards themselves, which can lead to self-directed bias and self-devaluation. Now, the second concept we wanna talk about is stigma, weight stigma. And that refers more to the social stereotypes that we encounter in our society. For example, that people living with obesity are lazy, unintelligent, lacking willpower or lacking motivation to engage in healthy behaviors and to manage their own obesity. Now, this is one of the concepts that we’re gonna talk a lot about today, about this lack of a motivation aspect and how we can change this narrative to reduce weight bias and stigma. The third concept is weight discrimination, which is when we treat people who have a higher weight or people who live with obesity in an unjust or unfair manner, meaning that we’re not giving them the same treatment that we give other people who don’t have obesity who don’t have a higher weight. Now, I talked a little bit before about this social stereotypes. And so where do these social stereotypes come from? And how do they affect our healthcare practices including in this slide here, public health practices? So this is a slide where you can see where obesity is framed in a very simplistic manner. You can prevent obesity easily through ABC. It says you can adopt new healthy habits. You can bike to work instead of driving to work. You can eat a balanced diet instead of eating fast food. You can go swimming instead of watching TV. Those are, you know, it’s easy. You just need to adopt these healthy habits. The second point B is balance your caloric intake. You just make sure, you know, you eat healthy and don’t eat too many calories. And the third one is C, you just have to control your weight gain. And the implication of this message is that people have control of their own weight, and that weight and obesity are behaviors that people can control. And when we frame obesity as a behavior, then we tend to cast blame on the people who are living with obesity. The idea is that people who are living with obesity, you know, are just not healthy, they’re They’re not engaging in healthy behaviors. They’re not eating the right foods. They’re not exercising. And they’re simply just not controlling their own weight gain. And that can cause a lot of stigma in society, in healthcare, and in our personal lives. Now, what is the evidence about this lack of motivation and lack of discipline and willpower that people living with obesity have? This is the action study that we did in Canada in 2019. This study has been produced in many different countries. I’m only showing you here the Canadian data that shows that when we surveyed people living with obesity as well as healthcare professionals and employers. So the purple box is people living with obesity. The middle box is healthcare professionals and the green box to the right is employers. And what we found here that there’s a huge discrepancy. So healthcare professionals and all three groups, patients and employers have high levels of weight bias and do consider obesity to be a lifestyle behavior, a diet and exercise behavior problem rather than a complex biological chronic disease. Many of these groups, including healthcare professionals, agree that obesity is a chronic disease, but they really believe that the treatment and the prevention strategies that can prevent and treat obesity are simple, diet and exercise. And you can see here that 82% of people living with obesity said that they are highly motivated to manage their own obesity. And 82% have said that they’ve tried to manage their own weight for over a decade. But in the middle box, you see that patients, sorry, health professionals believe that patients are just not motivated to manage their own weight. And this is why they’re failing at managing their obesity. And on the other hand, on the green box, you see that employers think that if people just set their mind to it and motivate themselves enough, they would be able to manage their weight on their own. So there’s this discrepancy of that people believe that it’s a chronic disease, but they believe the causes of obesity are very simple diet and exercise. and they believe the treatments of obesity are very simple, diet and exercise. And that the root problem is the lack of motivation and lack of control and willpower on behalf of patients living with obesity. So how common is weight bias and stigma in society? This is North American data again, showing that people living with obesity experience weight bias and stigma from many different ages and many different settings. I just want to make sure that you can still hear me and everything’s okay. So 27% of children report being teased in school because of their weight. 71% of adolescents report being bullied because of their weight in the past year. And more than one third of the people, adolescents who responded to this survey, reported having been bullied for more than five years. And then on the blue box circle, you see 66% of adults who are undergoing a obesity treatment program report experiencing weight stigma from their doctors. And this is a study that was international from Australia, Canada, France, Germany, UK, and the US. And about 20 to 50% of all adults, regardless of their weight or body size, have internalized weight bias, which is the last blue box there. So 20 to 50% of the adult population feel bad about their own weight and want to change their weight, even though they may not have obesity. So weight bias in the healthcare setting is very common. This is a systematic review of over 41 studies over three decades, showing that most healthcare professionals have moderately statistically significant implicit and explicit weight bias attitudes. And this causes a lot of consequences for patients who are undergoing healthcare services. For example, some of the impacts are listed in the last blue box here. Patients feel that healthcare professionals are not attentive to their health concerns or spend sufficient time listening to them during the consultation. Patients perceive patronizing or disrespectful language. Many perceive that the provision of healthcare they receive is of less quality. And this tends to lead to patients avoiding healthcare services and avoiding obesity treatment services. This is a study from Canada again, showing the impact of weight bias from the perspective of patients living with obesity. And I’m gonna read you the quote on the left side, which says, “There is such a stigma there that is reinforced. But when I enter the health system, the first place, I expect to talk candidly about my issue. I hear the blame. Well, you know, if you eat right and exercise, you will lose weight. It’s as simple as that. It’s a simple thing. That’s what I get. Obesity is so simple. When patients hear these comments from healthcare providers, it can cause them to lose trust in their healthcare providers and it can impact the healthcare communications. So the quote on the right-hand side says, “Weight bias negatively affects patients’ engagement in primary healthcare through their perceived barriers to healthcare utilization, expectations of differential healthcare treatment, low trust and poor communication, avoidance or delay of healthcare services and doctor shopping.” So when patients enter the healthcare conversations, the clinical conversations, they’re going to be thinking about different types of weight bias and stigma that they may have experienced. One of them is perceived stigma. This is where they perceive that the healthcare provider is using negative comments, whether they’re explicit or implicit comments, they perceive this negative attitude from healthcare providers and this judgment from healthcare professionals. And then there’s the experience stigma, which is the direct mistreatment that they may experience from a healthcare provider, meaning for example, that healthcare providers may treat them differently in clinical settings. They may provide less screening for cancer, for example. We have evidence that women living with obesity receive less screening tests for cervical cancer because healthcare professionals don’t want to interact and work with women who have obesity. Internalized stigma is again, as I mentioned, that self-devaluation. So if people have experienced all these negative comments throughout their lives and have experienced this direct discrimination or mistreatment, they’re going to internalize those comments and those negative experiences. And they’re gonna start believing that obesity is their fault, that they should be able to motivate themselves to change their weight. They should be able to motivate to stay engaged in an obesity treatment program, even though it’s not working for them. So they blame themselves for any obesity treatment failure, thinking that this is their personal fault rather than the treatment is not working for their specific obesity phenotype. And then there’s the anticipated stigma. So even before they come in to talk to you as a healthcare provider, they may have experienced weight bias and stigma from somebody else, another healthcare professional, not you, somebody who you perhaps don’t know. And when they come in to see you, they expect that you’re also going to be judgmental and they’re going to be expecting you to be treating them differently. And perhaps they’re expecting that there’s not gonna be any accommodations for them in your clinic, even though the reality is very different. Perhaps you have been receiving a lot of training on obesity and you have done a lot of sensitivity training of your staff and they’re not going to experience that. But because they’ve experienced that somewhere else, they kind of expect to be getting it everywhere. So this anticipated stigma has huge consequences for how they talk to you and how much they trust you in their clinical conversations. Now, the key aspect of internalized weight bias and how that can affect health communications is also important to remember. So for us, in order to internalize weight bias and stigma, there’s this process where first we have to become aware about obesity. So say the stereotype is that people living with obesity are just lazy or people with obesity are not motivated to manage their obesity. So you’re aware of that stereotype. You’ve heard it before. People have said it to you. You see it in the media, you see it everywhere. And then you start thinking that you need to apply this to yourself. Well, you know, I haven’t been able to manage my own obesity, so I must be lazy. I’m obviously not motivated enough like other people who have been able to manage their own weight. So it’s the awareness of the stereotype plus the application of that negative stereotype and applying to oneself that causes that internalized stigma and that can lead to people, self-devaluating themselves. So they start thinking, well, because I have obesity and there is a stereotype that people with obesity are lazy, I must be lazy and people with obesity are not motivated, so I must be unmotivated. So I am less hardworking, I’m less capable, I’m less motivated, and hence, whatever treatment I try, it’s not gonna work. So it doesn’t matter what treatment I try because there’s something wrong with me. So this thinking can have huge consequences for clinical conversations, and we need to be aware of it in our clinical conversations. Internalizing that way bias can also lead to poor mental health outcomes. And studies have shown that actually believing oneself to be deserving of all this negative shame and blame about their own weight can actually cause more harm to our psychological health than the actual experience of stigmatizing practices and discrimination acts. So believing yourself to be deserving of weight bias, believing that it’s your fault, believing that weight is your fault and that you did this to yourself, that can produce worse psychological outcomes than the actual stigmatizing experiences that they may get from others. And this causes this vicious cycle. You know, this is a study, a paper that we did on childhood obesity that when people, kids are being bullied for their weight, it tends to affect their self-esteem, depressive disorder. They start skipping school because they don’t wanna be shamed or bullied for their weight. They start removing themselves from social involvement that causes more stress and overeating and unhealthy control, obesity control behaviors such as yo-yo dieting, et cetera, which increases the risk for obesity overall, which then increases weight-based teasing and bullying. So it’s a vicious cycle that people get stuck in when people try to live with this disease and try to address their disease on their own and experience this shaming and blaming throughout their lives. This is a slide summarizing the health impacts, the physical health impacts, the psychological health impacts, and the impacts on healthcare delivery, which is what we’re focusing on in this webinar. So weight bias can affect the trust between healthcare providers and patients. It can affect the communications between patients and healthcare providers, and it can impact patient engagement in healthcare services, including primary care healthcare services, but also in obesity treatment services. So all of this to say is that we have enough evidence today that this widespread misconception that obesity is merely a lifestyle risk factor, that people are not motivated to manage their own weight, these messages come from this diet culture that we live in, rather than talking about obesity as a chronic disease. This, along with the frequent neglect that people with obesity experience in the healthcare system and in society, plus the persistent stigmatization that they experience in schools and the media, et cetera, it really undermines fair access to healthcare and equal opportunities for people living with obesity. And one of the biggest misconceptions that I’ve seen is that if we shame people with obesity, it will help them motivate themselves to change their own healthcare-related behaviors, such as taking their medication or attending follow-up sessions or exercising more or engaging in other health-related behaviors. But this belief that shame can motivate behavior change and that individuals have control of their own weight 100% is a root cause of weight bias and stigma. We have to remember that weight is not a behavior. I cannot control my own weight. About 40 to 70% of our weight is genetically developed and weight may or may not change when I change my health related behaviors such as eating healthier or exercising more. So framing weight as a behavior produces more shame because it contributes to that belief that people with obesity are just simply not controlling themselves enough. They’re not motivated enough to engage in healthy behaviors and controlling your own weight. And this has built now more and more evidence when people feel shame and when people experience shame from healthcare providers, it can actually cause biochemical, cognitive and behavioral changes that impact health outcomes directly, regardless of a person’s BMI or obesity or health-related condition. So experiencing shame increases cortisol levels, increases fat absorption, which increases risk for obesity. It can also affect your brain in that you start craving unhealthier food, for example, which also increases your risk for obesity. So shaming people can actually increase your risk for obesity. So we need to change the clinical conversation because obesity is not a behavior. Weight is not a behavior. Public health messages about eat less, move more contribute to that message that weight is a behavior and that people can control their own weight solely through individual behaviors. And so far the focus has been very widely on let’s create more willpower in people. Let’s motivate them to change their behavior. And it hasn’t really, the treatment for obesity has not really focused for very long on the fact that this is a chronic disease, a biological disease, as well as a behavioral disease, but it’s not an only behavioral disease. And we’re ignoring the lived experiences of people who have tried to manage their own disease for decades on their own. We have to remember obesity is a chronic disease characterized by dysfunctional or excessive adiposity that impairs health and shaming, whether it’s explicit, implicit or internalized, does not motivate people to engage in health promoting behaviors. The opposite is fact and facture. So we can do a lot of things. And in this webinar, we’re focusing on the interpersonal intervention and individual level intervention. So we can create policies at the institutional level. we can create strategies to reduce weight bias, stigma and discrimination at the population level. But here we can do something about how to address our own healthcare practices to reduce weight bias and stigma. So the first one is individual, assessing your own implicit, explicit and internalized weight bias attitudes. And then the interpersonal is really reflecting on how those individual attitudes and beliefs about weight and obesity are affecting our communications with healthcare professional, with patients who live with obesity. And we obviously recommend at the European Association for the Study of Obesity, as well as many other obesity professional societies, that we need to use person first language to reframe obesity as a chronic disease. So instead of saying obese patient, we say patient living with obesity. Instead of saying morbidly obese patient, we say patients with severe or complex obesity. Instead of calling patients non-compliant, we talk about treatment non-adherence. And instead of saying, is this patient appropriate for this intervention? We can reframe that and say, is this treatment appropriate for this patient’s obesity phenotype? And rather than framing, you know, unsuccessful weight loss as unsuccessful obesity treatment, patients, for example, when people say, patients fail to lose weight with this intervention, well, the treatment didn’t work. Treatment was not effective for this patient or for this patient’s obesity phenotype. Patients do not always have to be blamed for these treatment failures. The treatments can fail patients. And it’s important to always remember that obesity is a chronic disease. That means that throughout the disease trajectory, patients are going to need different types of treatments. And some of them may be psychological treatments. Some of them may be behavioral treatments. Some of them may be medications or bariatric surgery. And throughout their journey, they’re gonna need different types and different levels of those treatments. It’s not just one treatment works for everybody. So we can create a lot of different solutions, but in the current clinical practice guidance, we always encourage healthcare professionals to deliver patient-centered care. And Violeta is gonna talk very much about this, but the first thing that we need to do in order to reduce this weight bias is to really not assume things about the person living with obesity And don’t assume that the person is even ready to talk about their obesity. Just ask for permission to talk about their weight and their health condition, and then reframe it as obesity is a chronic disease. We need to do a full medical assessment to determine what is causing the obesity and how we can treat it. And when we discuss a collaborative patient-centered plan, we discuss it collaboratively with the patients based on what the patient needs. So the takeaway is that weight bias is everywhere. It can be implicit, explicit, or internalized. And we need to think about our own attitudes. So first we check in with ourselves, what are our own beliefs and bias attitudes about weight and obesity? The second step is we need to reflect on are we making assumptions about people because of their weight? Can we avoid those assumptions? The third step is person-centered healthcare, which Smiljata will talk about. And then using respect for terminology and imagery in all our healthcare communications, and really critically assessing how we’re talking about obesity. Are we talking about obesity as a chronic disease or a lifestyle risk factor or a behavior problem? And of course we need to shift the focus of obesity treatment from just behavior or interventions to include multidisciplinary aspects and address weight bias and stigma across healthcare settings. So thank you so much for your attention and I’m gonna end the presentation right now. Thank you.

Professor Jason Halford • 26:57
– Thank you very much Ximena. Excellent to hear that presentation and some excellent slides as well. So hopefully those will be available through the Definitely brilliant happy to share it. Okay, so we’re now going to move on to our second speaker Dr. Violetta Maris, our Connie and I so apologize for murdering your surname there Violetta Violetta is going to be talking to us about applying motivational interviewing to obesity care building trust and and supporting change. So thank you very much Violeta, take it away.

Dr. Violetta Maris • 27:33
– Thank you very much for inviting me and of course for sharing this beautiful webinar with Ximena and with you Jason. So thank you Lisa and the ASOCOMS team for organizing. So it was wonderful to hear Ximena and to consider how in this case motivational interviewing is between the intersection of the inflection point to help all these change in a very nice direction. So, well, first of all, I have no potential conflict of interest relating to these participations. I do have a new grant and I do participate actively in different role in many societies with the idea of contribute with my experience and knowledge. all being said, well, we are within this paradigm shift in the approach to obesity that the Canada, Canadian guidelines helps us to understand a long time ago already, almost six years ago. And as a nutritionist, it was very helpful, helpful to me to see how the treatment is going to support all the presumed changes that the person has to make in order to be more healthy. And this includes adding nutrition at the same level of exercise, substance abuse, healthy relationship, stress and sleep. And this decrease the pressure and the binary, this binary message of eat less, exercise more. So I am sure the IASO community is far away from this message already, which is great. So we are now in the same page trying to consider that all the changes, the lifestyle changes have to be addressed in all these topics. And for that, we do need intervention and treatment is psychological intervention, pharmacological and bariatric surgery and diet is not the treatment. So this is also nice to go into this new journey or the pathway that also the Canadian guidelines helps us to understand, to shift with the 5A that Ximena already mentioned, but I’d like to highlight here one important thing. Of course, they are considering motivational interviewing because here is a collaborative relationship. As we see in Agree on Goals, well, we assume we need to collaborate with the person to get a good treatment, the best treatment that goes for, that works for them. And for that, we assume that motivational interviewing as a way to be with the person is a great option. And these help us to move away from the model centered on the therapist and the disease against the patient center model, which is the one we are promoting, of course. And so the center, the model centers on the therapist and disease is when the patient has a passive role and the patient is the recipient of the treatment. Also, the doctor dominates the conversation, making too many questions, right? Like you can answer with yes or no. And also it focuses on the disease and the doctor and the therapist talks a lot during the consultation. On the other side, by contrast, the patient has an active role. We start the conversation asking, how can I help you? What can I do for you? if you agree, please tell me about your previous experience, etc. So we collaborate with the patients, offering options, learning from their own experience. And we of course are going to focus on quality of life if that’s okay with our patient and the doctor listen more than talks and talks less and of what is of interest for our patients, not what we consider interest. So this model, the model centred in the therapist and the disease was still present and is still present. I just finished my agenda today and still had to work with them in order to help them also to shift from this model. And this is how we enter in this personal centred care when we try to manage or to consider the five, the six elements of patient centred care that are all these ones that you are seeing here, so we encourage their values, their physical measurements, of course, that’s why we do have here the in-body to do this, and also we control their emotional needs, their social needs, the medical diagnosis, and we specifically centre on their strengths, and not on the weakness, but we need to consider them too. So this focus on the whole person, rather than just their medical conditions. And this helps us, as I was saying, to shift the therapeutic goals and the therapeutic focus towards improving patient-centered and health outcomes. And here is how we ambition or how we see this new frame, right? We have this beautiful umbrella that will help to fight stigma with education and also to be willing to learn how to learn from the patient experience with the specific methodology that we use. And of course, using motivational interviewing as a key element that can help us transform the approach to obesity. And we can do that tomorrow. I mean, if we can, with all that we have been listening today, and during this talk too, can apply something tomorrow, perhaps we cannot do everything, but we need to be able to choose one thing we can start applying tomorrow to contribute more positively to this engage, different way to engage with our patients. And with this ambition, and with Ximena and other professionals in a collaborative paper, we designed, we did this review about motivational interviewing and how it is helpful to cultivate the person-centered supportive clinical conversations with the idea and the aim to reduce stigma. So for those of you that are not familiar with the definition of motivational interviewing, so this is a person-centered clinical interview that helps explore and resolve their ambivalence about an unhealthy behavior or habit to promote changes towards a healthier lifestyle. So is the thing we need to help them to navigate and resolve. The ambivalence is normal. So we all face it during many times in the day, during our lives. And actually it’s a state of mind in which a person has conflicting feelings about something. And well, as I was saying, I saw this right today. A person was trying to fight their sedentary lifestyle And she punctuated from 10 to 10, the importance of that change in behavior, living their sedentary lifestyle for her own health. So even when they find it very important, they have other commitments, other barriers that are so interfering with the fact that, with the change that they want to do. So ambivalence is normal. We have to help them to evoke the desire for change and to also try to discover the way they can fight the barriers to get this done. So this is what also Blythe Pascal was mentioning and we used always to speak about motivational interview when we use this quote, that people are generally more convinced by the reasons they discover themselves than by those explained to them by others. That’s the reason that supports the idea of don’t tell our patients what to do, but instead collaborate with them in discovering themselves what they can do, what is realistic for them to do. So, and this is how motivational interviewing strength the patient-provider relationship. Decreased health-related stigma, but also increased empowerment and internal motivation, and also shows more support and respect for their own autonomy. So also, motivational interviewing can mitigate implicit bias and create this shared experience and mutual understanding. So how we communicate to patients interferes with the therapeutic response. And at this point, we need to stop for a second and think how we do this with our patients. Because this is what we were doing during long time until we learned how to. So I am working with this collaborator, when people living with obesity 25 years ago. And even when I was always interested in motivational interviewing, I still learned. And of course, this is a learning process and it takes time, but it’s normal, our desire to fix what doesn’t work in the people we serve, because we think we can quickly facilitate and improve their quality of life. But this is not motivational interviewing and we shouldn’t tell our people what to do, how, when and why. That’s exactly the work of our conversations that we can get done by communicating with motivational interviewing. And this brings us to the theory of the reflective listening of Gordon in the 70s. And it’s important to consider how to do, but also it’s important to consider how we not need to act. I mean, how not to act. And we don’t order direct, we don’t alert or treat our patients. We, of course, also not give advice. This is important to consider also in support groups, right? We don’t make suggestions or suggest solutions unless they ask for it. We also avoid persuading with logic or discussion or be teaching. And we don’t need to agree or disagree. We don’t need to approve what they decide to do. We of course need to avoid blaming, ridiculing, or labelling our collaborators. We don’t need to reassure, sympathise, or confront. We don’t question or test. We don’t get distracted. We don’t make shocks or change our subjects of the topic we are talking about suddenly, just because. So we need to avoid all these in order to really do an active listening. And this is a very important skill that we need to communicate well and do this with motivational interviewing. So, there are like three different common styles of communication. These are lead or guide or accompany, right? And depending on how much we inform, ask or listen to them, we are placed in one of these three styles of communication. So when we are leading, we inform a lot, we ask something, we ask a little, and we don’t listen too much. In contrast, when we accompany someone that is going through a difficult situation or we are listening to even our co-workers or friends, we mostly listen in and we can ask a little bit and we don’t at all inform. And when we are guiding we inform us and listen at the same level but we do inform with permission and options, we also ask but with open questions and we listen with really intention and this has to be done with the active listening. And as Bill Miller and Rolnik defined in their one of their first books, motivational interviewing can be defined as a refined style of guidance. And the nice thing of motivational interviewing is that the spirit that is also defined in the book is based on collaboration, on acceptance, on compassion and also in evocation. We do want to collaborate with them versus confront them and for that we need to form this alliance with our patients, our collaborators. we try to evoke versus educate them so the patient can generate their own solutions that are very important for change. And then we are based on acceptance, acknowledging the patient’s proposals because he is responsible for their own change. And of course, we are based on compassion versus indifference. And this is our, again, genuine interest in promoting the other’s well-being. So we can base the principles of behavioural change in these four steps. These are the facets that the person goes through when they are facing any change in their life. So the first step is for healthcare professionals to create this bond with the patient using the motivational interview spirit and style of communication. All these you can find in this paper that I was presenting before and is attached with this in this webinar so it’s available for all of you. So this includes using the person-centered and emphatic listening. So for the healthcare professional, we need to ask ourselves, does my patient feel comfortable talking to me? Have I generated an empathetic and supportive clinical environment? And I, you know, can question myself, was I distracted? Was I giving full attention, etc. And from their side, well, they also question themselves if we were professionally listening to them and if, to what extent we understood them. And from the patient’s side, right, they can say, do I feel like I can trust this healthcare professional? Can I safely and openly express my opinion on what happens in the consultation. Actually, those would be a beautiful question to have in a conversation with them during the first visit. But going through all these, we are making sure we engage, we have a nice bond that is important in order to help them to move towards any change they want to do. So in this second step, we want to identify a clear therapeutic treatment goal by focusing this clinical conversation on patient’s goals and values. We always do a parallelism with motivational interviewing and with the tango, actually, that is a dance from typical from Argentina, I’m sure you all know. So we ask ourselves, are we dancing tango or boxing in doing our conversations? Of course, we want to dance the tango. That is a coordinated dance that is important to be taking care of one other to do it well, right? Because we need to know that when we are not focusing on the same goal, this is a clinical discordance. And this is directly proportional to the distance between our patient’s goals and those that are proposed by the healthcare professionals. So here, the question we need to do is what really matters to our patients in order to focus on what really is important for them. So the third step would be evoking. And here, for healthcare professionals to evoke a patient’s intrinsic motivation, we need to change all the plans, we need to make all these in order to make sure we have a realistic plan, as I was saying before. And we go back here to this quote that Blaise Pascal, that we were mentioning before about that they are more convinced by the reason they discovered themselves from themselves than whatever is being told. So at this point, the question is, what are your real reason for change? And this is a beautiful open questions that can be done to help us understand and propose a plan or create a co-create a plan that is fitting or filling their expectations. And the last step is planning. So this step occurs when the patient decides to undergo behaviour change and makes the change into action, deciding goals and strategies to achieve these goals. So here we want to know what are the strategies that can best fit your values because we know that there are not the same strategies working for all of them. So doing this needs skills and these skills are being continuously trained. So actually this is an intention, this webinar is an intention today to spark your interest in motivational interviewing and to promote this continual learning since you never know enough of motivational interviewings and it’s important to have a group of discussions where we can actually discuss clinical cases to know how to better address them. So regarding the skills that we need to be able to do this process, we need to do an open and the questions we do to do we need to do affirmations for instance and as stated in the paper right you have really put a lot of effort into changing your sleep habits or for instance it sounds like you have been very dedicated to your stress management routine. Two minutes. Thank you. So this is important also to consider how we have to affirm how the we can or need to reflections and in the end, but very important to be able to learn how to summarise all that has been happening during our encounters. So here there are some open questions as an idea that I leave it here in my presentation just for you to make it easier or to create your own ones. Just this is an schema of the motivational interviewing just to see all together how we place this in action. Right. We have the processes, engaging, focusing, evoking and planning. We have the spirit of collaboration, acceptance, compassion, evocation. And we have the abilities or right. And all this is to avoid discordance and to give answers to our patients. So just to finish in one minute, I just tell you a little bit about the importance of of learn and how to evaluate and collaborate with patients to evaluate patient experience. And for that, in our living lab, we do have a place where we can do different actions. In this case, we were doing a workshops to help them express emotions and needs through the drawings. This was a very nice workshop. Instead of a typical consultation that we did, they were able to use it to evaluate their stigma perceptions, they feel and express these by drawing and explaining in a group all their feelings. We ended up publishing this paper, so it’s also available for you and is important to help them understand different ways to consider all these. So some new key message of the recently published obesity guidelines, in this case, the Spanish one, well, I like to highlight how we try to say in sententious words. So we are avoiding saying sententious words. This was a big change. Also, we avoided using sententious images, make value adjustments or attributing any illness or complain to excess of body weight are now including the new guidelines. So avoiding all these terms. And how can we help our patients? Well, so listen more than we talk, ask open questions, shift to patient-centered care, leverage past experience, promote new skills, explore self-efficacy, elicit personal reasons for change. And of course, always because it’s the privilege that we have individualised the treatment and avoiding blame, of course. This is just my thank you slide for all the group of motivational interview with the Shetem group that we collaborate and we work together. We aim to do bees as therapists, no flies, because you know where flies go. So we focus always in the sweet, in the good things. That is how we do the affirmations we want to be. And she has an invitation to join us, into them, to have nice moments and learn about motivational interviewing. So thank you very much for your attention. Thank you Violeta and Ximena.

Professor Jason Halford • 52:07
I’m now opening up to question and answers. Please remember to use the Q&A box. And the The first question we actually have is, are you able to share any resources to help healthcare practitioners practice motivational interviewing outside of a patient appointment? So outside that clinical setting, can you give us some guidance?

Dr. Violetta Maris • 52:30
– Yeah, I mean, we also have the clinical setting we do in, well, basically in any action we do for the community and like this workshop I was showing you, we, anytime we encounter them. So we try to do activities based on what they want to do. And of course we can do outside the clinics, just don’t give, don’t tell people what to do and asking, you know, open questions, even to our friends, our relatives. These will improve our relationship with everybody if we try to learn anytime that we talk to them.

Professor Jason Halford • 53:15
– Brilliant. I think it’s also might be worth pointing out at this juncture, we actually have a talk at ECO around how to scale up psychological approaches beyond the clinic as well. So look out for that, that’ll be by Laura Palmera. Okay, the next question is, could you expand a little bit on the planning aspect and how instructive teaching is suggested.

Dr. Violetta Maris • 53:43
Great. This is wonderful. And of course, this was just, as I was saying, the interest of this was to spark the interest because we need a whole session, a course actually to do this. But the planning needs to be done, well, the teaching needs to be done with a group, right? The MINTI group are the people that are qualified to teach motivational interviewing and every region has their own MINT team. So please make sure to go into the MINT in your area and you will find people trained and certified to teach in motivational interviewing and about the planning. Well, it’s all about asking and listening and reflecting, and we will be able to develop and co-create a plan that works for them.

Professor Jason Halford • 54:34
Brilliant. Somebody wants to know, is more interested about how can we make sure that all healthcare practitioners of differing backgrounds, this is a multidisciplinary team in our centres, are aligned on delivering high quality motivational interviewing?

Dr. Violetta Maris • 54:49
Yes, this is a very good question. Because sometimes, just because it looks reasonable, right, to act as, as we were talking about, I mean, of course, I will do that. And we all think we do that. But it’s not easy and we need training and practice. That’s the reason we have this group. I am very lucky because I have this great team in Spain that they started it with addictions, right? That’s how Motivational Interviewing started. So they are working in addition. And at some point we merge and we are collaborating in our support groups. they come over and we do the group treatment. So how, well, I think we could offer a certification, but it has to be one, yourself have to be a critic enough to see if you really are trained and active based on motivational interviewing skills.

Professor Jason Halford • 55:49
– Brilliant, okay, just to follow on, any tips for helping colleagues engage with what we know is best practice, just quickly.

Dr. Violetta Maris • 55:57
– Okay, yes, inviting them to the motivation and interviewing workshops, and also inviting them to the patient experience living lab to listen to our people, and they will say what we need to change.

Professor Jason Halford • 56:15
– Brilliant. Okay, one more question. I try to evoke thoughts and reasons within patients to focus on health rather weight numbers. Do you have any advice?

Dr. Violetta Maris • 56:28
For focusing on health rather than weight, well, many, many ideas. I don’t know if you’ve advised, but ideas could be like, well, actually asking the reasons why they want to change. And you know, we know that, for instance, vegetarian diet have a positive effect for health independent of weight loss. So by asking them if they want to learn more about this, we can try to focus on more in the quality of the diet rather than quantity. And this is an example, but we can do this for sleeping and for other kind of behaviours they need to change.

Professor Jason Halford • 57:10
Right. One more question, possibly the last question we’ll take. How do you manage a patient that during interview you find there is a psychological issue? I’m assuming this might be a mental health issue and how and should be advised to see a specialist psychologist

Dr. Violetta Maris • 57:26
psychiatrist. Definitely motivational interviewing does not substitute the psychological treatment of course but the good thing with motivational interviewing is that they can share and openly express what they need and what they feel and of course we need to take care of that and I do the consultation or I invite our psychologist from the team and we do the treatment together or themselves. I mean this is not excluding, this is including and we all need to be training on that, the multidisciplinary work, even the administrative staff, we are all part of

Professor Jason Halford • 58:07
this. Brilliant, okay well I’d like to thank both our speakers here Violeta and Ximena. I think There’s a question there about where can we find interview workshop and that will be provided. Just a reminder, our eco is coming up in terms of psychology, behaviour and mental health. We have a session on trauma and trauma-informed care and obesity. We have a session on third generation psychotherapists following on from our excellent last year on motivational interviewing, which covers acceptance and commitment therapy, mindfulness and compassion-focused therapy, as well as trauma-based therapy. We have a special session on stigma in healthcare systems, learning from other disease states, such as HIV and mental health. We have a session on neurodiversity and obesity, focusing on ADHD. And we also have an interesting talk on neurodevelopmental conditions and eating difficulties as well in TRACT2. So plenty of psychology relevant to treatment and informed by patients in the up and coming program. Now, I think I’ve run out of time now and Lisa’s going to cut me off.

Professor Jason Halford • 59:14
So again, thank you for your attention and have a great week. Bye. Bye Bye.