1. Identifydentify the stages of behavioural change, analyse ambivalence, and use communication

1.1 Behavioral change models in Nutrition  

Changing dietary behaviours is a complex process influenced by numerous psychological, social, and cognitive factors. The effectiveness of dietary interventions does not rely solely on conveying knowledge about healthy eating, but requires consideration of the patient’s readiness to change and the adaptation of communication methods to their individual resources and limitations. To this end, approaches based on behavioural change theories and models are employed, allowing for precise tailoring of interventions to the needs of the individual. 

This part of the module primarily discusses the Transtheoretical Model of Change (TTM) by Prochaska and DiClemente, which describes the change process as a sequence of stages: precontemplation, contemplation, preparation, action, maintenance, and relapse. Understanding which stage the patient is in enables more effective planning of therapeutic and educational activities. 

Another key tool covered in the module is Motivational Interviewing (MI) – a communication method focused on strengthening the client’s internal motivation through empathetic listening, formulating open-ended questions, paraphrasing, and summarising. MI techniques such as OARS, as well as the DARNCATS concepts, form the foundation for effectively supporting the patient’s/client’s decision to change dietary habits. 

Special attention is also given to adapting educational content to the patient’s/client’s cognitive and motivational level, which is particularly important when working with individuals suffering from mental health disorders. Addressing emotional and cognitive barriers in the process of acquiring dietary knowledge enables more realistic and effective planning of interventions. 

A model approach to behavioural change, grounded in theory, motivation, and individualised communication, constitutes the foundation of effective dietetic and psychodietetic practice. 

Commentary to the dialogue:  
In this example: 

• relapse is not treated as failure, but as a normal stage in the process, 

• the social worker uses empathetic and normalising language (e.g. “It’s part of the process”), 

• shifts the focus from “I’ve failed again” to “what has already been achieved”, 

• encourages a return to action without demanding immediate change – creating space to rebuild motivation. 

 The Prochaska model in working with individuals with eating disorders – what does the research say? 

In working with individuals suffering from eating disorders such as anorexia or bulimia, it is common to encounter situations in which the client does not feel ready for treatment or does not recognise the problem. Although the illness has serious consequences for both mental and physical health, many individuals are unwilling or unable to initiate change. This is precisely why Prochaska’s Transtheoretical Model of Change can be particularly helpful in social work with this group (Hasler et al., 2004). 

A study conducted at an eating disorders clinic involved 88 female patients diagnosed with anorexia, bulimia, and other eating disorders. Each person’s stage of readiness for change was assessed (e.g. precontemplation – lack of awareness of the problem, contemplation – ambivalence, action – active attempts to change). A specialised self-assessment scale (URICA) was used for this purpose. Additionally, the study evaluated whether the patients were engaging in specific techniques that support change, such as recognising emotions or adopting new behaviours. 

What does this mean for the social worker? 

1. Motivation for change is a separate topic that should be identified and nurtured in the client – regardless of whether they have previously been in therapy or not. 

2. The social worker should observe the client’s behaviour: Are they making efforts to change? Are they opening up emotionally? Are they actively seeking support? 

3. It is beneficial to tailor conversations and interventions to the stage the client is currently in (in line with Prochaska’s model). 

4. Focusing on the emotions related to the disorder can help the client move forward – emotional engagement may be a key step toward change. 

The study shows that change does not begin with action, but with readiness, which develops gradually through stages. Even if the client is not yet ready, we can support them in this process – through conversations, joint planning, and by helping them emotionally process their difficulties. 

Bibliography

Prochaska, J. O., & DiClemente, C. C. (1984). The transtheoretical approach: Crossing traditional boundaries of therapy. Homewood, IL: Dow Jones-Irwin. Prochaska, J. O., DiClemente, C. C., & Norcross, J. C. (1992). In search of how people change: Applications to addictive behaviors. American Psychologist, 47(9), 1102–1114. https://doi.org/10.1037/0003-066X.47.9.1102 Prochaska, J. O., & Velicer, W. F. (1997). The transtheoretical model of health behavior change. American Journal of Health Promotion, 12(1), 38–48. https://doi.org/10.4278/0890-1171-12.1.38

1.2. Concept of motivational interviewing

Motivational Interviewing (MI) is a conversational approach that supports individuals in changing their habits, particularly those related to health. Its goal is to strengthen the patient’s internal motivation – encouraging them to change in a way that makes them want it for themselves. Instead of telling someone what they should do, the person conducting the conversation helps them reach their own conclusions (Miller, 2022; Miller & Rollnick, 2013). 

This method was developed by William R. Miller in the 1980s. Initially, it was used in working with individuals addicted to alcohol, but later, together with Stephen Rollnick, Miller expanded the approach to help people with other health issues such as obesity, hypertension, diabetes, and physical inactivity (Miller, 2022; Cole et al., 2023). 

In traditional health conversations, we often encounter instructive statements such as: 
a) “You need to stop drinking so many energy drinks – they’re bad for you.” 
b) “You should eat more vegetables, or you’ll have health problems.” 

In motivational interviewing, the approach is different. Instead of lecturing, the interviewer helps the patient come to the realisation themselves that change is beneficial. Rather than confrontation, the focus is on understanding, empathy, and collaboration (Miller, 2022; Cole et al., 2023). 

Thanks to this approach, the patient does not feel forced into anything, but instead comes to the conclusion on their own that it is worth making a change (Miller, 2022; Miller & Rollnick, 2013). 

Where is motivational interviewing used? 

Although it was initially applied mainly in addiction therapy, today it is used in many fields, such as: 

• Lifestyle medicine – e.g. supporting changes in diet and physical activity. 

• Clinical psychology – e.g. in therapy for individuals with depression or anxiety disorders. 

• Dietetics – helping people adopt healthier eating habits. 

• Cardiac rehabilitation – supporting post-heart attack patients in changing their lifestyle. 

Due to its effectiveness, this method is recommended by various health organisations as an effective approach to helping people change their habits (Cole et al., 2023). 

Four processes of motivational interviewing

1.2.1 Engaging

The first step in Motivational Interviewing (MI) is engagement – establishing a strong, trusting relationship with the person we want to support. The goal is to make the patient feel that they can trust us, and that we are not here to judge or pressure them. Only when someone feels understood and accepted are they more likely to open up to a conversation about changing their habits. Three key techniques that help with engaging the patient are: 

1. Active listening – showing genuine interest in their feelings and thoughts. 

2. Open communication – avoiding closed questions that only allow for “yes” or “no” answers. 

3. The OARS tools – a set of communication techniques that support connection and motivation. 

Active listening – how to show you’re truly listening 

Active listening means giving your full attention to the person you’re speaking with. It’s not just about hearing their words, but about understanding what they truly want to express. Showing empathy is also essential – demonstrating that you understand their feelings without judging them. 

What does active listening achieve? 

✔️ Helps build trust and a sense of safety. 

✔️ Shows the other person that they matter to us. 

✔️ Makes the patient feel heard, rather than lectured. 

It’s important to remember that engagement is the first step in an effective conversation – the patient must feel that they can trust us. Through active listening, we can show the client that we understand them, which encourages them to keep talking. Supportive responses demonstrate to the client that their feelings matter and that they are not being judged. 

Here is a comparison of open-ended and closed-ended questions presented in table format: 

Open-ended question	Closed-ended question	Explanation (additional Information gained)
What does a typical day look like for you when it comes to eating?	Do you have regular meals?	Allows the patient to describe their daily rhythm, identify hunger times and eating habits, giving a fuller picture of their lifestyle.
How do you feel after meals?	Does eating affect your mood?	Provides insight into emotional and physical reactions to food and reveals unconscious links between emotions and eating.
What helps you maintain healthy habits, and what makes it more difficult?	Do you struggle to maintain healthy habits?	Helps the patient identify their strengths and barriers, as well as what supports or hinders them in sustaining healthy behaviours.
What are your experiences with trying to change your diet in the past?	Have you tried to change your diet in the past?	Opens space to analyse previous attempts, reasons for setbacks, and potential success factors for future efforts.
What happens when you feel a strong urge to eat in stressful moments?	Do you eat when you’re stressed?	Offers deeper understanding of stress-related eating patterns and identifies triggers and alternative coping strategies.
What emotions do you feel when eating alone, compared to when eating with others?	Do you prefer to eat alone or with others?	Helps uncover how social context influences eating habits and what emotional responses are linked to different situations.
What do you see as the biggest obstacles to changing your eating habits?	Do you have any difficulties changing your eating habits?	Gives the patient space to explore and articulate specific challenges and consider their own solutions.
What makes some days easier and others harder in terms of eating?	Are there days when it’s harder to keep a healthy diet?	Encourages reflection on daily struggles and helps identify factors that influence the ease or difficulty of maintaining healthy eating.
What do you think could help you eat more regularly?	Do you know what you could do to eat more regularly?	Invites the patient to consider realistic, personal strategies for improving meal regularity rather than providing a quick or superficial answer.

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Summary – why is OARS effective? 

Technique	What is it?	Example
O – Open-ended questions	Questions that require a longer answer	“What do you think about your eating habits?”
A – Affirmations	Positive comments that strengthen motivation	„It’s great that you’re making an effort to eat more vegetables!”
R – Reflections	Repeating what someone said in different words	„You don’t have much time, so you often turn to ready-made food.”
S – Summaries	Collecting and organising important information	„From what you’re saying, it sounds like you want to eat more healthily, but cooking is a challenge for you.”

Thanks to the use of OARS, conversations become more natural, and the other person feels truly listened to and understood. It is worth using these techniques not only in professional settings but also in everyday relationships – because everyone wants to feel that their emotions and thoughts matter. 

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1.2.2. Focusing

At this stage of the conversation, it is important to help the patient decide what they want to focus on. The aim is not to tell them what they should do, but rather to ask what matters most to them. 

This stage is very important because: 

• The client chooses the topic of the conversation, which increases their engagement. 

• We don’t impose change, but help identify the area that most needs attention. 

• We don’t correct or criticise the client, but instead work together to find the best path toward change. 

It’s important to avoid the “righting reflex”. Often, when we see someone doing something unhealthy, we feel the urge to immediately point it out and tell them what they should do differently. However, this approach can make the other person feel judged, leading them to become defensive. 

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1.2.3. Evoking

How to ask questions that strengthen change talk 

📌 Instead of: “Do you know that sweets are unhealthy?” 
✅ Better to ask: “What would you gain if you reduced the amount of sweets in your diet?” 

📌 Instead of: “You should eat less fast food.” 
✅ Better to ask: “How do you feel after eating fast food? Is there anything you’d like to change?” 

📌 Instead of: “Why don’t you cook at home?” 
✅ Better to ask: “What might make it easier for you to prepare meals at home?” 

Eliciting change talk 

Miller and Rollnick (2013) identified seven categories of change talk, which can be remembered using the acronym DARNCATS. These categories are detailed in the table below. 

Category	Description	Example of patient’s statement
D – Desire	Desire to change	‘I’d like to eat better.’
A – Ability	Ability to change, feeling it’s possible	‘I think that if I try, I can eat more healthily.’
R – Reasons	Reasons to change	‘If I lose weight, I’ll feel more confident in my body.’
N – Need	Need for change, showing it is important	‘I need to change my diet because my blood sugar is high.’
C – Commitment	Commitment to change, open declaration	‘From today, I’m going to plan my meals for the whole week.’
A – Activation	Readiness to change	‘I feel like I’m ready to start eating regular meals.’
T – Taking steps	Taking steps toward change	‘Yesterday I went shopping and bought healthy food.’

To encourage the client to express change talk, you can use questions inspired by the DARNCATS framework.
Examples of questions for the patient: 

• Desire: “How would you like your diet to look in a few months?” 

• Ability: “What could help you make small changes in your eating habits?” 

• Reasons: “What would you gain by cutting down on sweets?” 

• Need: “What health risks are making you think about changing?” 

• Commitment: “What could you do today to start improving your diet?” 

• Activation (Readiness): “On a scale from 1 to 10, how ready are you to make a change?” 

• Taking Steps: “Have you already done anything to improve your eating habits?” 

Strategies for Reinforcing Change Talk. 
After hearing change talk, it is helpful to use techniques that strengthen it: 

• Highlighting positive aspects: “It’s great that you’re thinking about planning your meals. What else could you do?” 

• Deepening reflection: “What makes this change important to you?” 

• Summarising the patient’s statement: “So, you’re saying that you’d like to eat more healthily because you’d have more energy and feel in a better mood?” 

Comparison of effective vs. ineffective scaling in assessing a patient’s readiness for change. 

Type of scaling	Example question	Why it works or doesn’t work
✅ Good scaling	“On a scale from 0 to 10, where 0 means you’re not ready at all and 10 means you’re fully ready to change, how would you rate your readiness to cut back on energy drinks?”	This question allows the patient to assess their own readiness, encourages reflection, and avoids pressure.
❌ Poor scaling	“You’re ready to change, right? Maybe around an 8 or 9?”	Suggesting a high number can trigger a defensive reaction and discourage an honest answer.
✅ Good scaling	“Okay, you said your readiness is at 5. What makes it a 5 and not a 3 or 4?”	Helps the patient recognise the positive aspects of their motivation and reinforces change talk.
❌ Poor scaling	“Why only a 5? You should want change more than that.”	Provokes guilt and may lead to resistance to change.
✅ Good scaling	“What might help you raise your number by one or two points?”	Encourages the patient to explore their own solutions and plan realistic next steps.
❌ Poor scaling	“Why aren’t you at 10? This is important for your health.”	Creates pressure and negative emotions, which can shut down open, honest communication.

Simulation of a Conversation: DARNCATS in Practice 

🔹 D – Desire – Expression of the wish to change 
Social Worker: “Karolina, you mentioned that you drink quite a lot of energy drinks. Have you ever thought about what your life might look like if you drank fewer of them?” 

Karolina: “Yes… Sometimes I think it would be nice not to need them every day. Maybe I’d feel less tired during the day.” 

🎯 Technique: The social worker helps Karolina recognise her internal desire for change. 

🔹 A – Ability – Belief that change is possible 
Social Worker: “You mentioned that you’d like to cut down on energy drinks. What do you think could help you with that?” 

Karolina: “I think I could try drinking more water or find other ways to feel more awake… But I’m not sure I can do it, because it’s been my habit for a long time.” 

Social Worker: “That does sound like a challenge, but I noticed you already have some ideas for alternatives. That’s really important! What could help you follow through with that plan?” 

🎯 Technique: The social worker strengthens Karolina’s belief in her abilities by highlighting her own ideas. 

🔹 R – Reasons – Specific reasons for change 
Social Worker: “And what do you think you would gain by cutting down on energy drinks?” 

Karolina: “I’d probably sleep better, wouldn’t have those sudden drops in energy… Besides, I know those drinks aren’t healthy, and my body is already weakened as it is.” 

🎯 Technique: Karolina lists her own reasons for change, which strengthens her motivation. 

🔹 N – Need – Emphasising the importance of change 
Social Worker: “You’re saying your body is weakened and that these drinks don’t make you feel good. How important is it for you to do something about it?” 

Karolina: “I think it’s really important… The doctor told me I have vitamin deficiencies and that coffee and energy drinks might be making it worse. Sometimes I feel like I should do something about it, but I lack motivation.” 

🎯 Technique: The social worker helps Karolina recognise how important this change is to her. 

🔹 C – Commitment – Clear declaration of action 
Social Worker: “If you feel this is important, what could be your first step toward that change?” 

Karolina: “Maybe I’ll try to drink one less energy drink a day and replace it with water or lemon tea?” 

🎯 Technique: Karolina defines a specific step herself, which increases her sense of control over the change. 

🔹 A – Activation (Readiness for Action) – Expressing readiness to change 
Social Worker: “That sounds like a good plan! On a scale from 1 to 10, where 1 means you’re not ready at all, and 10 means you’re fully ready to act – how would you rate your readiness for this change?” 

Karolina: “Maybe a 6. I’d like to do it, but I’m afraid I won’t manage.” 

🎯 Technique: The social worker checks Karolina’s readiness for change and can encourage her to reflect on what might increase her motivation. 

🔹 T – Taking Steps (First Steps) – Taking action toward change 
Social Worker: “That’s great that you’re at a level 6! What might help you move up to a 7 or 8?” 

Karolina: “Maybe if I had a clear plan and reminders on my phone… or if someone supported me.” 

Social Worker: “That sounds like a great idea! Maybe to start, you could try writing down how many energy drinks you have each day and we’ll see how it looks over the week?” 

Karolina: “Yes, I could do that. I’ll try starting tomorrow!” 

🎯 Technique: Karolina clearly begins taking action, which increases her chances of success. 

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1.2.3. Planning

To facilitate the client’s transition from thinking to action, Brief Action Planning (BAP) is used – a planning method based on four basic questions: 

Bibliography

Miller, W. R. (2022, July). Motivational interviewing: Evolution & new developments [Webinar]. Plenary address presented at Columbia School of Social Work. Miller, W. R., & Rollnick, S. (2013). Motivational interviewing: Helping people change (3rd ed.). The Guilford Press. Cole, S. A., Sannidhi, D., Jadotte, Y. T., & Rozanski, A. (2023). Using motivational interviewing and brief action planning for adopting and maintaining positive health behaviors. Progress in Cardiovascular Diseases, 77, 86–94. https://doi.org/10.1016/j.pcad.2023.02.003

1.3. Adapting communication to the cognitive and motivational level of the client.

Cognitive functioning level – meaning how a client perceives the surrounding reality, remembers, and processes information – directly affects how they understand their difficulties and how they assess their ability to implement change. In some cases, a realistic evaluation of both their situation and their capacity to make necessary changes is not fully possible. 

Many individuals with mental illnesses (e.g., schizophrenia, depression, bipolar disorder, anxiety disorders) may experience cognitive deficits – even if these are not immediately visible „at first glance.” 

In the context of changing eating behaviors, this has crucial importance because: 

• the client may not understand recommendations regarding a healthy diet, 

• they may forget what they were supposed to eat or when, 

• they may not notice the connection between food and their well-being, 

• they may feel overwhelmed by too much information. 

Adapting the language and the way information is delivered increases the likelihood that the client will understand it and be able to take the first step toward change. 

Practical tips – how to adjust communication 

1. Ensure a good atmosphere and conditions for the conversation, and adjust the pace of your speech to the client’s abilities 
   🔸 Example: If the client gets distracted easily, turn off your phone, close the door, speak more slowly, and observe whether the client is following your message. 

2. Use simple, everyday language 
   🔸 Instead of: “Please increase your fiber intake” 
   🔸 Say: “Try eating an apple or a slice of whole grain bread every day – it helps with digestion and mood.” 

3. Break information into small chunks and repeat it 
   🔸 Example: Don’t go over an entire daily meal plan in one session – start with breakfast. 
   🔸 Say: “Let’s focus just on breakfast for now – tomorrow morning try eating something warm, like oatmeal.” 

4. Use written notes or simple visuals 
   🔸 Example: Create a note with the client listing three healthy lunch ideas and stick it on the fridge. 

5. Ask checking questions to ensure understanding – without judgment 
   🔸 Example: “Would you like to repeat what we agreed on together?”, “How do you understand this?”, “What do you remember from this conversation?” 

6. Give choices and strengthen a sense of control – don’t say ‘you must’ 
   🔸 Example: “You could try water instead of cola today – what do you think, can you try it once a day?” 

7. Reinforce and validate small successes 
   🔸 Example: “Great that you bought apples – that’s an important step. I’m glad you managed to do it!” 

1.4. Cognitive and emotional barriers in acquiring nutritional knowledge. 

Remember: 

• The client may understand less than it seems – nodding doesn’t always mean comprehension. 

• Always check understanding – for example: “Can you tell me what you remembered from our conversation?” 

• Less is more – it’s better to communicate one thing effectively than five things chaotically. 

The most common emotional barriers and what you can do about them 

Remember: 
 

• Emotions are the key to change – not an obstacle. If you understand them, you’ll help more effectively than any guidebook. 

• Acknowledging the client’s emotions is the first step towards building trust and readiness to cooperate. 

• Changing eating habits is a very personal matter – it should be approached with great sensitivity.