How we use Motivational Interviewing in our feeding therapy practice

Ever worked with a kiddo who was making excellent progress in the clinic, but zero progress at home? Yeah, us too. Thankfully less and less these days, thanks to one of our favorite therapy tools…Motivational Interviewing!

There are a lot of reasons why we love Motivational Interviewing (MI) and we’ve got a whole post on that here! We want to focus in this post on examples of how we use MI in our pediatric feeding therapy practice to help get on the same page with a parent and to help parents make necessary changes that support their child. Before we jump into the detail of how we use MI in our feeding therapy practice, let’s re-visit the case of our friend Max, who we introduced in our last post about MI.

Max and his family were struggling with picky eating and mealtime battles. They were majorly stressed and overwhelmed. Max was 3 years old, was not gaining weight well, and was developmentally a little delayed. Aside from this, however, all of the GI and ENT work up came negative, yet Max was not eating enough and was severely picky.

During my assessment, I was able to identify two main issues-

1. Max was grazing and over-snacking throughout his day.

2. Max’s developmental delay caused him to be a slow and inefficient eater so we needed to work on a mix of self-feeding and endurance for sitting at the table.

I recommended that the family implement a more defined mealtime schedule to get Max listening to his body’s cues, eating more regularly and tasting new foods. This was work the family would have to do. Yes, I would be helping them make the schedule and problem solving behavior management for family meals, but it was up to the family to make these changes and consistently use the schedules I offered. Max and I would also need to work in therapy on his sitting balance, trunk control, & endurance for remaining seated comfortably for the duration of a meal.

When mealtime routines, oral motor exercises and food chains are not enough

Starting out as new grads we were so eager to learn all there was about oral motor skills, food texture progression and self-feeding activities, but it turns out that very little of that matters when the child you are working with has a parent that is not ready to follow through with the changes that are needed to make real and lasting improvements in the child’s eating.

We knew the parents weren’t to blame, that they needed help to see things could be different, support to see where their own beliefs and behaviors were getting in the way, and then guidance to find their own motivation to want to make changes before we ever got to the final phase (every therapist’s favorite part!) of offering our expert recommendations on what changes might help their child eat. We just didn’t know how to provide that support in an organized way.

Intervention for the parent

We finally found that magic tool about 5 years ago when we learned about MI and it has quickly become our favorite strategy for supporting parents with all the “precursor” skills we noted above that allow them to actively make changes in their parenting.

For anyone not familiar, Motivational Interviewing is an evidenced based collaborative approach created by Miller & Rollnick, that is used to help people express why they want to make a change and then move towards that change. We’ve got a whole post on why we love MI so much that you can read HERE if you haven’t already seen it.

To be honest, when we first learned about MI, despite how simple it sounds, we found it hard to put into practice! We knew it could work for us but translating it into motivation for a parent to make changes to the family on behalf of a child was a little bit of a stretch and took some creativity and a lot of practice. We wished we had some examples that hit at our population, since most of the videos and examples we saw were about an adult trying to change their own behavior (quitting smoking, losing weight, leaving an abusive relationship, managing diabetes, etc.).

Our goal here is to provide a few of those scripts and ideas that are specific to feeding therapy. This is not a comprehensive “how to” for MI. We assume that you have either taken a course or read a book on MI to learn the basics. If you have not already taken a course on it, we strongly recommend it! MI is a research supported intervention so we think it fits into just about every therapists’ toolbox.

We also aren’t going to take you through all of Max’s case from beginning to end. We’re actually just going to highlight one conversation (out of many) that I had with Max’s mom about implementing a daily mealtime schedule using “meal windows” aka “meal zones.”

Motivational Interviewing in action in a pediatric feeding therapy session

After an evaluation and agreeing on a plan of action, I found that Max’s parents were not using any of the strategies I recommended and that they had agreed to try. When I asked Max’s mom about whether she has started using the flexible mealtime schedule that I had proposed and tailored to their particular needs, mom quickly shut me down with, “Ugh. I wanted to but no, I haven’t done it yet. Actually it’s kind of impossible for us because I’m just insane right now. Max has preschool 3 days a week and the other days I’m running around working and doing errands with him part of the day while his dad has him all afternoon and then [his sister] gets home and we’ve got to get her to soccer…it’s just not going to work.”

My knee jerk response is always to start thinking of all the ways I can solve each issue mom brings up, but this sort of response will often encourage mom to start thinking up all the ways that my ideas won’t work for her. So instead, my first intervention is a silent one inside my head where I quiet that part of my own brain that wants to push back and argue, by using a tool that I find magic: empathy. I think about how horrible it feels to me when I am both overwhelmed and powerless to do something that I know I should be doing. Feeling and expressing empathy for this mom is a key principle of MI and allows me to use another key element of MI—summarizing back to the person what he or she just said— in a more meaningful way because now instead of coming across as annoyed or condescending, I can authentically say, “Wow, that’s a lot. It sounds like you really wanted to try the feeding schedule but it feels kind of impossible with all that you’re managing.” This lowers mom’s guard a bit [in the evaluation she seemed a bit defensive and I wanted to make sure I didn’t trigger her in this conversation] and she agrees, “Yeah. You have no idea. [Max’s sister] started soccer, work is crazy, and [Max’s dad] has been traveling.”

When I provide mom a brief recap of what she said to me, instead of just empathizing and repeating back mom’s language about how she was so busy, I also summarize and repeated back another thing mom also said, “it sounds like you really wanted to try the feeding schedule…” which picked up on a tiny piece of what’s called, “change talk” in MI lingo, that mom casually dropped into the conversation. It was that small line where mom said, “Ugh. I wanted to...”

Change talk is when a person states a positive intention to make a change or states a reason why they want to make a change (in this case, mom is acknowledging she wants to use the meal schedule I recommended.) This is in contrast to “sustain talk” which is stating that you don’t want to make a change or listing reasons why you can’t or shouldn’t make a change.

Change talk is incredibly important. It’s the person convincing him or herself to make a change and stating reasons why they want to make the change. The more change talk a person expresses in a conversation, the more likely he or she is to stick with it and successfully make a change! So man important goal of MI is asking questions that elicit change talk.

At this point, I can see that mom is starting to focus on all the reasons why she’s too busy to even think about using my crazy meal zones schedule. In the past, I might have just let mom rant and kept empathizing because I want mom to feel heard but MI has given me the tools to hear mom, empathize, but gently steer the conversation back towards a more productive and therapeutic place.

There were a few directions I could have taken this conversation from here and I want to explore a few possibilities.

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Scenario 1 (picks up where we left off above)

Me: Oh my goodness, that is a lot! You wanted to try the meal zones but you’re just swamped this week. I totally understand, no problem at all. I heard you also say you didn’t think it was going to work for you. Is that right?”

Mom: “yeah, not right now. We’re just too crazy.”

Me: “I see. It’s hard to implement something new when you’re so swamped.”

Mom: “Exactly.”

Me: “Ok no problem. So can I ask you a few questions though so I can figure out where to go next?”

Mom: “Sure.”

Me: “No pressure here- there is no right answer and zero judgement from me. I just want to make sure I know what’s a priority for you and also what you think is feasible for you right now. So when we spoke last time, I mentioned that there are 2 main things we need to work on, one was helping Max build his body strength and the other was helping him start to feel hungry so he’ll be more motivated to eat. Is that second one, helping him feel his hunger still a priority for you?”

Mom: “Yes, absolutely it’s still a priority. It’s just hard with all that’s going on right now but I still want to work on it.”

Me: “Ok, great. You have a lot going on but you’re also dedicated to working on this and the meal zones schedule is particularly challenging. Is that right?”

Mom: “Well, yes and no. The meal schedule is not challenging. It’s just that [Max’s dad] is traveling this week so it’s totally insane.”

Me: “Oh, ok, I see. So this week is particularly challenging with [Max’s dad] out of town but you still want to try the meal zones schedule in the future?”

Mom: “Yes.”

Me: “Ok great, so then can I ask you a few other questions?”

Mom: “Sure.”

Me: “What makes you feel more confident about sticking to the meal schedules when [Max’s dad] is here? Tell me a little bit about how you imagine that going.”

Mom: “Well, I think it will be much easier if I have some extra help, especially on Sundays so I can grocery shop and meal plan and in the mornings.”

Me: “That makes sense. And I love that idea to do meal planning on Sundays. That can save so much time during the week.”

Mom: “Yeah, otherwise I just get so stuck on what to serve it’s easier to just feed him the [nutrigrain] bars.“

Ok let’s pause here and talk about this snippet of conversation. So you can see we started at a pivotal moment where mom is starting to spin off into all the reasons why she couldn’t do the meal schedule and if I had let her rant without steering her back in, that might have been the end of that really important part of my therapy plan. But right when she’s spinning out, I guided her back in by asking a few questions to help her get clear on her goals. As mom sees the discord between what she says are her goals and what she is doing, she starts to naturally steer herself back in by adding in solutions and reasons why she might be able to try again.

Truthfully, it’s possible mom might have used my questions to double down and say, “no this isn’t a priority for me right now.” Or even, “yes this is a priority but I still don’t have time for the meal schedules.” If that happened, that’s OK! I am not the one who gets to make rules and decisions for this family. However, it is my job to make sure mom is making informed decisions, which includes understanding the repercussions of her choices. So, if mom did say yes it’s a priority but no I can’t work on it now, I might have taken the conversation in this direction…

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Scenario Two (beginning where I ask mom if the schedule is a priority):

Me: “No pressure here- there is no right answer and zero judgement from me. I just want to make sure I know what’s a priority for you and also what you think is feasible for you right now. So when we spoke last time, I mentioned that there are 2 main things we need to work on, one was helping Max build his body strength and the other was helping him to feel hungry so he’ll be more motivated to eat. Is that second one, helping him feel his hunger still a priority for you?”

Mom: “Yes it’s still a priority. I’m just too swamped to manage the meal schedules. I need you to work on that with him.”

Me: “Ok I understand, you do want to help Max with understanding his hunger but you’re not going to be able to manage the meal schedules.”

Mom: “Yes. We’ll have to do something else.”

Me: “Ok I hear you. Would it be ok if I asked you a few more questions?”

Mom: “That’s fine.”

Me: “We talked about the meal schedules a little a few weeks ago. Can you just tell me what you remember of that conversation about why I was recommending them?

Mom: “To help Max avoid snacking so much and start to feel more hungry so he’ll eat more.”

Me: “Yes! Ok perfect. I apologize, I just wanted to see where I should start and I didn’t want to say things you already knew. Ok so you’re exactly right. Those meal schedules are super important if we want Max to feel his hunger and also learn to eat enough so that he feels full. There isn’t another way to teach him that skill without experiencing it by spacing out his meals. If the meal schedules don’t work for you right now, that’s totally understandable and absolutely ok- you know your family best. I do want to make sure you understand that we won’t be able to make progress in that area without them though. Does that make sense?”

Mom: “Oh, I see. Yes, that make sense.”

Me: “Ok, so just to confirm, would you like to set aside that piece of our plan right now, knowing that we won’t be able to make the kind of progress we discussed in helping Max learn to recognize his hunger and eat larger volumes. Or would you like to spend time in our next session problem solving the meal schedule a bit more together and continue with that important piece?”

Mom: “Um, I guess we can talk about it next session.”

Me: “Ok so this is still a priority to you and you’re willing to keep addressing it next week.”

Mom: “Yes that sounds good.”

Phew! So it’s possible that mom may throw a plot twist in there and try to ask for something that’s not really feasible. Our goal with using MI here is to help mom align her goals with her behavior and in this case what she is saying for her goals, does not line up with the action plan she wants to pursue. It’s our job to respectfully help her see that and offer reasonable solutions (or help her find her own solutions.) Helping her see the discrepancy allows mom in this scenario to at least come back to a contemplative phase where she agrees to keep discussing and thinking about it, rather than shutting you down entirely.

There are obviously so many different directions this conversation could go in- this is the tip of an iceberg!

But you can see here that MI is all about respect and asking key questions to help the parent come to their own goals and solutions. It’s very tempting to want to argue and “convince” a parent why they should make a change but in MI the research shows that the more a person comes to their own conclusions, the more likely they are to actually follow through.

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We love this topic and want to hear about your experience with it! Any scenarios where you get stumped with MI? Or do you have a MI feeding therapy success story? Share them with us in the comments! Also, if you’re as into MI as we are, we hope you’ll be excited to learn that we’re working on putting together a 6-hour online course on using MI in your feeding therapy practice! Sign up to our email list if you’re not yet subscribed to be the first to know when it’s launched!

Want more information on MI? You can check out motivationalinterviewing.org or buy the MI book: Motivational Interviewing: Helping people to change (3rd edition)