Is It the Best Approach to Behavior Change?

Here is a fundamental question coaches ask themselves as they apply their knowledge in the field: 

How can health, wellness, nutrition, and fitness coaches empower and motivate clients to adopt behaviors that support their long-term health? 

In other words, how can health coaches apply their skills and knowledge so that their clients actually feel healthier as they progress? 

Health behavior science is an approach to understanding how a person’s decisions and actions, or lack thereof, shape their health and wellbeing. It recognizes psychological, environmental, and social factors that influence and determine health behaviors. Health coaches and related professions are experts in applied behavior change, which is why they are always on the lookout for effective approaches to encourage behavior change. 

Motivational interviewing, infused with the principles of trauma-informed care, is considered by many as an extremely effective approach to behavior change. Motivational interviewing is used by client- or patient-facing health professionals, such as coaches, to create a space to openly communicate with clients and support them in being active leaders of their own health and wellness journey. Trauma-informed motivational interviewing utilizes the principles of trauma-informed care and applies them to evidence-based motivational interviewing practices to promote self-efficacy while also acknowledging the potential effects of trauma on how a person thinks and acts. 

This article describes trauma-informed motivational interviewing and summarizes the evidence of its potential for making a positive impact on health behavior change approaches.  

What Is the Difference Between Trauma-Informed Motivational Interviewing and Standard Motivational Interviewing? 

Motivational interviewing is a communication technique used by health professionals to create a safe space that fosters clients’ agency and self-efficacy regarding the if, when, how, and what of change. 

Through standard motivational interviewing, coaches generate guiding questions that will allow them to gain insight into where their client is on the health behavior change continuum. An important component of motivational interviewing is goal setting based on deep motivations and a realistic look at their current limitations and opportunities for health behavior change. 

According to the Motivational Interviewing Network of Trainers, “techniques are designed based on a respectful and curious way of being with people that facilitates the natural process of change and honors client autonomy.”

A trauma-informed approach recognizes that, unless health professionals are aware of how trauma and adverse events affect how a person thinks and acts, as well as how trauma influences health risks, they may unknowingly re-traumatize clients, even when they believe they are being respectful and curious. Re-traumatization is any situation or environment that reminds an individual of past trauma literally or symbolically and then triggers difficult feelings and reactions associated with the original trauma.

A trauma-informed motivational interviewing approach integrates the trauma-informed care principles to the motivational interviewing principles. 

The fundamental principles of motivational interviewing are: 

• Expressing empathy by use of reflective listening
• Developing discrepancy between client goals and current problem behavior by use of reflective listening and objective feedback
• Avoiding argumentation by assuming that the client is responsible for the decision to change
• Rolling with resistance rather than confronting or opposing it
• Supporting self-efficacy and optimism for change

The six key principles of a trauma-informed approach are:

• Safety: Clients should feel physically and psychologically safe in the coaching environment. 
• Trustworthiness and transparency: Coaches are clear about how they make decisions and what they will do with the information collected. The goal is to build and maintain trust with clients. 
• Peer Support: Provide or suggest opportunities for clients to seek out peer support and mutual self-help. 
• Collaboration and Mutuality: Recognize that there are power differences between client and health professional that society has set forth and work to level those power differences. 
• Empowerment, Voice, and Choice: Individuals’ strengths and experiences are recognized and built upon, and the how, when, what, and why of the services coaches offer aim to foster empowerment and self-advocacy skills of clients. “Clients are supported in shared decision-making, choice, and goal setting to determine the plan of action they need to heal and move forward.”
• Cultural, Historical, and Gender Issues: Coaches recognize and actively move past stereotypes and biases and incorporate policies, protocols, and processes that are responsive to the needs of individuals served. 

In short, a trauma-informed motivational interviewing approach infuses the principles of a trauma-informed approach into the motivational interviewing approach. 

Is Trauma-Informed Motivational Interviewing an Effective Approach to Health Behavior Change?

Motivational interviewing is an evidence-based style of communication that helps to promote health behavior change. Studies have demonstrated its effectiveness in coaching, nursing, pediatrics, dentistry, mental health treatment, and health education. 

Researchers and clinicians have highlighted how a motivational interviewing framework and the skills it cultivates can be used in a trauma-informed coaching approach. 

In fact, the unification of trauma-informed care and motivational interviewing principles “create a climate of safety and trust, and effectively elicit and strengthen clients’ motivation for change.”

Subtle But Important Differences Between a Trauma-Informed Vs. Non-Trauma-Informed Motivational Interviewing Approach 

A person well-versed in motivational interviewing but unaware of how trauma might be affecting a person’s health, wellbeing, mentality, and development may offer information or ask questions that are seemingly respectful but may make the client uncomfortable, maybe even reliving traumatic experiences. 

A non-trauma-informed motivational interviewing approach may: 

• Ask about circumstances the client is not comfortable sharing
• Overlook social determinants of health 
• Use triggering or judgmental language  
• Ignore cultural, historical, and gender issues that have an influence on the client’s way of communicating and what they feel comfortable speaking about, values and decision-making process, and others. 

The values of a trauma-informed approach help to fill gaps in motivational interviewing to serve people who have experienced trauma. The subject matter and goals addressed in both trauma-informed and non-trauma-informed motivational interviewing may be the same, but how health professionals ask the questions may differ.

For example, a motivational interviewing approach that is not trauma-informed may phrase a question as a statement or command:

“So you mentioned that you didn’t have a good experience with your previous health coach. I’m sorry about that. Tell me about it.”

While the health coach is expressing empathy and seeming respectful, the information the coach would like to gain access to (what happened that made the client feel like they didn’t have a good experience) is phrased as a demand. This does not promote a sense of choice or recognize that the client may not feel comfortable or safe to talk about it. 

Instead, a trauma-informed version of the previous question may be: 

“In your previous response, you mentioned that, overall, you didn’t have a good experience with your health coach. That must have been hard, and I’m sorry. Would you feel comfortable telling me why you feel that way? The information will help me respect your needs and avoid repeating the same mistakes.”

While both communications aim to hear the same information from the client, the second response helps to foster safety and a sense of choice while also communicating transparency as to why the information might be relevant. 

Main Takeaways

Trauma-informed motivational interviewing is a tool for building an authentic connection with your client, understanding their circumstances and way of thinking, and creating a non-judgmental space for critical thinking and problem-solving. 

Keep in mind, however, that no single strategy is a be-all, end-all approach. Even with clients that respond constructively to trauma-informed motivational interviewing, it should be paired with other approaches and tools that you see fit, which may include communication techniques for transmitting information, goal setting, modeling and learning in action, and imagining scenarios.  

If you want to implement trauma-informed motivational interviewing with your clients, do your best to keep lines of communication open so you can receive feedback on how they are feeling with their progress, how you can improve, and whether or not they feel trauma-informed motivational interviewing is an effective tool for them. 

References

1. https://commonfund.nih.gov/behaviorchange
2. https://www.safetylit.org/citations/index.php?fuseaction=citations.viewdetails&citationIds[]=citjournalarticle_204313_20
3. https://journals.sagepub.com/doi/abs/10.1177/1942602X15576777
4. https://diabetesjournals.org/care/article/33/8/1741/39134/A-Randomized-Controlled-Trial-Comparing
5. https://journals.lww.com/jopte/Abstract/2015/29020/The_Use_of_Motivational_Interviewing_in_Physical.9.aspx
6. https://ncsacw.samhsa.gov/userfiles/files/SAMHSA_Trauma.pdf
7. https://depts.washington.edu/fammed/wp-content/uploads/2015/06/501MI.pdf