Counseling Tips for Nutrition Therapists Series
Copyright notice: Permission is granted to print and duplicate these Tips on two conditions:
- This must appear at the end of each Tip:
2006 Molly Kellogg, RD, LCSW
- Don't edit the copy at all without checking with me.
first 50 Tips and much more are in my Practice
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
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.
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
the risk of burnout.
You may become resentful when clients cancel
often or don’t pay on time.
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:
know what to
expect and can make decisions accordingly.
those who feel guilty for canceling, they know you are being compensated for your time.
policies support your professionalism
and therefore your credibility.
of policies in nutrition practices that you can use if
are due at the beginning of the session.
are collected at the beginning of a block of
a client is more than one session behind on payment,
no appointments are scheduled until the balance is
only (or cash only).
cards accepted only for blocks of sessions.
credit-card impression is taken at the first visit,
and late-cancellation and no-show fees will be
flat fee is charged for a returned check.
an appointment canceled less than 24 (or 48) hours
before the scheduled time, the full fee (or a lesser
fee) is due.
only exceptions are: dangerous weather,
emergency-room visits, sick child, etc. (you decide
ahead and state it clearly).
must be made by phone, not e-mail.
must be made by phone and e-mail.
no-shows, the full fee (or a lesser fee) is due.
and no-show fees are collected at the beginning of
the next session.
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
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
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
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
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
Finally, a note about what can make
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
to list of Tips
Tip #52 Matching Your Client’s Style
Every object, every being,
is a jar
full of delight.
Be a connoisseur.
Behind every difficult
person or situation is
a blessing just waiting to be revealed.
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.
everything is a problem to be fixed.
person, meaning in life comes from connections
everything is to be understood through research and
the artist, the
use of intuitive creativity and beauty may be the
life is a series of competitions.
it’s striving to follow God’s will in everyday
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
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.
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
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
you hear the client use key words that you understand
but never happen to use, try using them with this
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
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
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.
to list of Tips
How to Handle Gifts From Clients
A gift blinds the wise and
perverts the words of the righteous.
To receive gifts is to lose freedom.
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
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
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:
how this gift fits into the treatment process,
especially if the timing seems odd.
The gift is not about you, it is about the
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.)
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.
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:
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.
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
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
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.
to list of Tips
#54 Watch Your Language
How often misused words
generate misleading thoughts.
If you wish to know the mind of a man,
listen to his words.
Humans are profoundly affected by
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:
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
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?”
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
some humor, remind the client, “Oh, here comes that
‘have to’ again.”
Other situations where language is
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
role in the counseling process: If
you cringe when a client calls you the “food
police” or the “boss,” insist on shifting this
not the boss here.
This is your life and health we are working
on. I am
more like a coach or consultant.”
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.”
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
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
to list of Tips