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Counseling Tips for Nutrition Therapists Series
2006 Archives

Copyright notice: Permission is granted to print and duplicate these Tips on two conditions: 

  1. This must appear at the end of each Tip:
                   © 2006  Molly Kellogg, RD, LCSW
                   www.mollykellogg.com
  2. Don't edit the copy at all without checking with me.

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The first 50 Tips and much more are in my Practice Workbooks

Counseling Tips for Nutrition Therapists: 
Practice Workbook series

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Tip # 51   Setting Professional Limits Around Fees  (9/1/06)
Tip # 52   Matching Your Client's Style  (10/1/06)
Tip # 53   How to Handle Gifts from Clients  (11/1/06)
Tip # 54   Watch Your Language  (12/1/06)

Tip # 51  Setting Professional Limits Around Fees

Desire, ask, believe, receive.
Stella Terrill Mann

Learn the rules so you know
how to break them properly.

The Dalai Lama

Clear limits on all aspects of your working relationship with clients create a therapeutic structure within which you will be most effective.  The important issue of time boundaries on sessions is explored in Tip #21 (Available in the Practice Workbook, Vol 1. This Tip will look at some other limits: collecting fees and handling cancellations and no-shows.

What establishing and maintaining clear limits does for you:

  • Reduces the risk of burnout.  You may become resentful when clients cancel often or don’t pay on time.
  • Provides a more reliable income.
  • Supports you in the difficult moments when you need to discuss fees.  For example, if you have a clear policy on late cancellations, you do not need to think it through each time; you simply state the policy.

What clear limits do for your clients:

  • They know what to expect and can make decisions accordingly.
  • For those who feel guilty for canceling, they know you are being compensated for your time.
  • Clear policies support your professionalism and therefore your credibility.

Examples of policies in nutrition practices that you can use if they fit:

  • Fees are due at the beginning of the session.
  • Fees are collected at the beginning of a block of sessions.
  • If a client is more than one session behind on payment, no appointments are scheduled until the balance is paid.
  • Checks only (or cash only).
  • Credit cards accepted only for blocks of sessions.
  • A credit-card impression is taken at the first visit, and late-cancellation and no-show fees will be charged.
  • A flat fee is charged for a returned check.
  • For an appointment canceled less than 24 (or 48) hours before the scheduled time, the full fee (or a lesser fee) is due. 
  • The only exceptions are: dangerous weather, emergency-room visits, sick child, etc. (you decide ahead and state it clearly).
  • Cancellations must be made by phone, not e-mail.
  • Cancellations must be made by phone and e-mail.
  • For no-shows, the full fee (or a lesser fee) is due.
  • Late-cancellation and no-show fees are collected at the beginning of the next session.
  • Late-cancellation and no-show fees must be mailed to the office before the next appointment is scheduled.

If you are new in practice or wanting to institute clearer policies, develop statements to say on phone calls.  Practice the sentences and phrases that you will need as issues come up, such as “I got your message about needing to cancel today.  I’ll see you at our time next week.  It would be fine to bring your late-cancellation fee then,” or “I’ll give you a call when I get your check for the canceled appointment so we can reschedule.”  

Write down your policies.  Give them to the client at the first visit, put them on your Web site, or mail them to a client before the first visit.  Some clinicians ask clients to sign a copy of the office policies and give the clients a copy.  For late-cancellation and no-show policies, some print them on the back of their business card or state them in their outgoing voice message.

Some clients need these boundaries more than others.  If you have been in practice for a while, you have likely discovered this already.  There are always clients who forget their checkbook one session but have it the next, and they never expect too much of you.  Your gut tells you that reminding them of your policies once is enough.  

Then there are the clients who push your limits over and over.  Likely they will do this in several areas such as session time boundaries, time on the phone, fee payment, lateness and/or cancellations.  With these clients, you feel as if you are dealing with a 3-year-old.  Three-year-olds test parental limits over and over.  Parents know that young children thrive when given gentle, consistent limits.  As they mature, most children internalize limits and learn to accept new rules as they encounter them.  Some clients have not completely internalized this ability to know and respond to boundaries.  They need reminders, and indeed, they will thrive when you maintain the boundaries. It is frustrating to do this with adults, but when you do, both of you will feel more secure and the work will go more smoothly.  

Therapists look at patterns of lateness, cancellations and late payment of fees as “clinical issues.”  They are talked about in session in the service of helping clients discover more about themselves and increase their degree of functioning in the world.  This is not part of your job as a nutritionist.  If your client is seeing a therapist, be sure to mention any such patterns to the therapist and ask for direction on the best way to handle them with this client.   

Finally, a note about what can make this limit-setting so difficult for some of us:  We work hard to be client-centered and empathetic in our practices.  When addressing the client’s goals and concerns, this is essential and effective.  However, when addressing issues of the “frame” around the work (the time, the location, the fee paid), a fully client-centered stance is not appropriate. You (and your business) are a significant part of that frame, and therefore, it is your right and responsibility to tend to that frame. It may help to imagine having an office manager (or actually having one) who sets the office policies.  You can shift into office-manager mode when discussing these issues. You may not enjoy this part of nutrition counseling, but that doesn’t make it any less essential.

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Tip #52 Matching Your Client’s Style

Every object, every being,
 is a jar full of delight.
Be a connoisseur.

Rumi

 Behind every difficult person or situation is
a blessing just waiting to be revealed.

Cheryl Richardson

We humans come in wondrous variety, and we approach the world with an infinite range of cognitive styles. These styles are usually enduring and mostly unconscious. They affect the client’s view of the world, self and others, and they significantly influence the client’s process of change. Working with a person’s style rather than trying to change it will increase your success rate. This means understanding who the person is and how her brain works. With some clients, it will involve setting aside your favorite ways of working.

Here are a few broad generalizations to begin to assess your client’s preferred style. In many people, several styles are blended.

  • To the engineer, everything is a problem to be fixed.
  • To the communal person, meaning in life comes from connections with others.
  • To the scientist, everything is to be understood through research and rational experimentation.
  • To the artist, the use of intuitive creativity and beauty may be the highest value.
  • To the athlete, life is a series of competitions.
  • To the devout, it’s striving to follow God’s will in everyday life.

You can pick up a client’s approach quickly through careful listening to language.  Subtle matching of your language to the client’s will build rapport and allow the client to hear you better. When you get used to observing and matching language, you can go to the next step and look for the deeper worldviews.  

If you are puzzled and wonder what style or styles fit a client, ask questions.  For example, “I just used the word ‘experiment.’  Is that OK or do you prefer I use another word in talking about these ideas you are going to try out?” or “I wonder what approaches to making changes in your life have worked for you in the past.  For example,  what motivated you to quit smoking all those years ago, and how did you do it?”  The answers  may seem odd to you.  See if you can roll with the client’s style even if it is very different from yours.  

Acknowledge the style out loud! Put into words the differences between you and the  client.  For example, “Boy, I keep going back to all these details about the biochemistry of diabetes and losing you, don’t I?  I’m sorry I’m slow catching on to your style.  You tend to look at these changes in terms of how they will affect your family.  Please remind me when I get off track again.”  

Some clients fit your style naturally.  They seem easy to work with and you likely enjoy them.  For example, you may approach problems with a scientific mind-set and love to research topics on the Web.  You will likely work smoothly with other such “scientists,” directing them to resources to aid their natural process.  

The challenge is working with a client who is very different from you.  Consider stretching yourself to fit more and more styles. The easiest way to do this is to employ the client’s own language.  When you hear the client use key words that you understand but never happen to use, try using them with this client.  With a client I find challenging, I write down her key words and worldview in the chart to remind myself of her style before the next visit.  

Expecting a client to change a whole outlook on life is unrealistic.  You are not trained to do this, and do not have an implicit contract to do this work with your client.  It is more realistic to be as flexible as you can, adapting your style to work within the client’s  approach to life.  You are asking your client to make dramatic changes to lose weight or get blood sugar under control.  When you allow the client to use her accustomed style and skills to accomplish these goals, progress is more likely.  

A caution: Sometimes by going along with a client’s style, you collude with the very thing that is holding the client back.  You may need to go along with and even support a client’s current process while holding the truth that this style is not normal or healthy.  You may decide to offer to work on changing it when the client is ready.  For example, some clients with anorexia have a rigid, ritualistic approach to life.  Indeed, this is a significant contributor to their illness.  It may be necessary in the first stages of recovery to use the client’s style, dysfunctional as it may appear to be.  Designing a rigid food plan may save this client from dangerous weight loss and hospitalization.  Someday, she may be ready to take the small steps toward a more normal process of feeding herself.  This treatment process involves a delicate balancing act.  Discuss it with the client’s therapist to ensure you are on the same page about the treatment goals.

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Tip #53  How to Handle Gifts From Clients

A gift blinds the wise and
perverts the words of the righteous.
Bible

To receive gifts is to lose freedom.
Sandi

As a general rule, gifts do not belong in a professional relationship. The interchange between you and your client involves payment of the fee and in exchange, your undivided attention and professional expertise. Gifts are not necessary and not appropriate.  However, we humans are social beings, and so there are exceptions.

Listen to your gut.  If something doesn’t feel right about accepting a gift, your intuition is telling you that a professional boundary is being breached. Find a way to graciously turn down the gift. The easiest way is to simply say that it is against your policies or, if you work in an institution, that it is against your employer’s policies.

Certain types of clients warrant more careful boundary-tending than others. This includes gifts. Those with Borderline Personality Disorder or with very low self-esteem are examples.  Clients who push other professional boundaries such as time limits and paying the fee on time may also offer gifts.  A handy rule of thumb is that these clients will benefit most from your counseling if you stick closely to professional guidelines and watch that the relationship does not slip into a personal one.

Dynamics to look out for:

  • Notice how this gift fits into the treatment process, especially if the timing seems odd.  The gift is not about you, it is about the client.  This is similar to personal questions that the client asks you. If this is a client you have worked with for a while, find out what brought about the gift at this time. You may find a way to respond to what is underneath the actual gift.  For more on this process, see Tip #18 (Available in the Practice Workbook, Vol 1.) 
  • A client with low self-esteem may give gifts in the hope you will like her or look at her as special. A client may compulsively give a gift because she believes she is  unworthy of your attention and professional care.  By consistently and  respectfully refusing gifts, you are gently asserting to this client that her value as a human being does not depend on gifts.  These are useful themes to discuss with the client’s therapist, if there is one.  Coordinating your stances on gifts and other issues will aid the treatment process.
  • When you suspect a psychological dynamic, discuss the case with someone.  This might be a supervisor, a colleague who works with similar clients, or the client’s therapist. You could come up with a plan for addressing this gift or at least brainstorm ideas for handling future ones.

Exceptions to the rule:

  • In some cultures, it is common to give a gift to professionals in certain circumstances.  If you work with clients of cultures very different from yours, work to understand the norms.  You could even ask clients for assistance in understanding the role gifts play in their world. 
  • Some clients will give a card or a gift of minimal value at the end of the year.  If you have worked with these clients for many months, this may feel appropriate. Some people routinely give such gifts every year to all the professionals they consult regularly.  Know your clients.  If this fits their style, it is likely appropriate.
  • If you decide that accepting a gift is appropriate, do so graciously in a “sound bite” and then shift the session back to your usual topics. I have discovered a subtle clue that a person is in the category of clients who warrant careful boundaries.  Such a client will dwell on the gift and seem to want an unusual amount of gratitude for it.  If this happens, tuck away the information and remind yourself to maintain tighter boundaries with this client.

You may be caught off guard by a client’s gift.  It’s handy to have a policy or generic response ready.  Social training takes over in these situations, and you may respond in a way you regret later.  It is useful to train yourself with a set of responses specifically for professional relationships. For example, “Oh, that surprises me since I make a policy of not accepting gifts from clients.”  Or, “It is customary in my profession to not accept gifts from clients.”  If you plan to accept it, maybe something like, “That was kind of you, though unnecessary.”

In summary, the question of whether to accept a gift needs to be resolved on a case-by-case basis. Listen to your intuition, and if that isn’t enough, ask for input.

Note: There is no mention of gifts from individual clients in the American Dietetic Association’s code of ethics.  Accepting gifts from vendors from whom you may make purchasing decisions for your employer would fall in the category of  “conflict of interest.”  This would also be true for gifts from companies that hope you will then recommend their products to your clients. This Tip is not about these relationships.

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Tip #54 Watch Your Language

How often misused words
generate misleading thoughts.
Herbert Spencer  

If you wish to know the mind of a man,
listen to his words.
Chinese Proverb

Humans are profoundly affected by words.  Your choice of words in a session can make the difference in whether the client makes a positive change. Here is a useful question to ask yourself:  Does my choice of words fit my intention?

Let’s take the example of an intention of promoting choice for your client, thereby making resistance less likely (Tip #47, available in Practice Workbook, Vol. 2).  Language such as “you have to…” or “you must…” takes away the client’s choice and increases resistance to change.  Instead use empowering language such as “I’d like to hear your ideas for handling this situation.” Or    “What do you believe will happen if you do this new behavior?”  See Tips #39, Use of Imperatives, and #37, The Power of Permission, (available in Practice Workbook, Vol. 2) for more ideas on language to promote choice.  The language of experiments (see Tip #3, available in the Practice Workbook, Vol 1.) also offers choice.  “Are you curious what will happen if you…”  “Is this an experiment you would like to do?”  

Notice your client’s language.  When a client uses imperatives such as “I have to…” you could offer alternative self-language.  For example, a client may say, “I have to stop drinking soda.”  You can agree with the proposed behavior change while challenging the client’s choice of words.  For example, “Well, you don’t actually have to do anything.  I’m not going to lock you up if you drink soda.  Would it be as true to say to yourself that you want lower blood sugars or to have more energy?  If you were to focus on those goals to pull you forward, would you probably choose something like water or diet soda instead?”  If the client agrees on this shift in language, it will be helpful for you to note when it slips back in.  With some humor, remind the client, “Oh, here comes that ‘have to’ again.”

Other situations where language is important:

  • Building your confidence: Especially if you are new to outpatient counseling, observe your language for weak statements, such as “you could come back for another visit if you want to.”  Training yourself to state what you know to be true builds confidence.  For example, “We can’t cover everything today, and there is more I can help you with.  I suggest another appointment in two weeks.  This will give you a chance to try out some of these ideas and bring your questions back to me.”
  • Your role in the counseling process:  If you cringe when a client calls you the “food police” or the “boss,” insist on shifting this language.  “I’m not the boss here.   This is your life and health we are working on.  I am more like a coach or consultant.”
  • Rapport: If you believe in building rapport with clients, use language that says this clearly.  “Let’s explore this more so you and I will be on the same page.”  “I would like to make sure I understand what is important to you.”
  • Setting limits: To communicate office policies to clients (see Tip #51) use simple, clear language.  “For an appointment canceled less than 24 hours before the scheduled time, a fee of $25 due.”  “I use e-mail only for scheduling and rescheduling, not for nutrition questions.”

This is only a beginning.  Look for other ways in which your word choice and your intentions don’t match and play with a better fit. 

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