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Counseling Tips for Nutrition Therapists Series
2007 Archives
Copyright notice: Permission is granted to print and duplicate these Tips on two conditions:
- This must appear at the end of each Tip:
©
2007 Molly Kellogg, RD, LCSW
www.mollykellogg.com
- Don't edit the copy at all without checking with me.
------------------------
The
first 25 Tips and much more are in my new Practice
Workbook
Counseling
Tips for Nutrition Therapists:
Practice Workbook, Vol. 1
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Table of Contents
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Now
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Tips #
26 - 50 are available now in an e-book you
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Counseling
Tips for Nutrition Therapists,
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Tip # 55 Working with Ambivalence
to Change (1/1/07)
Tip # 56 Effective Use of
Handouts (2/1/7)
Tip # 57 Steady Clients
Who Aren't Making Changes (3/1/07)
Tip # 58 Grief in
Nutrition Counseling (4/1/07)
Tip # 59 A Format for
Providing Advice (5/1/07)
Tip # 60 Open and Closed
Questions (6/1/07)
Tip # 61 How to Shift Your
Counseling to Mindful Eating (7/1/07)
Tip # 62 Family Members of
Clients (8/1/07)
Tip # 63 Affirming
(9/1/07)
Tip # 64 The Power of
"And" (10/1/07)
Tip # 65 The Righting
Reflex and How It Gets Us in Trouble (11/1/07)
Tip # 66 What You Don't
Know Can Help You (12/1/07)
Tip
#55 Working with Ambivalence to
Change
It is the mark
of an educated mind
to be able to entertain a thought
without accepting it.
Aristotle
Conditions for
creativity are to be puzzled;
to concentrate; to accept conflict and tension;
to be born everyday; to feel a sense of self.
Erich Fromm
Ambivalence is an inherent part of the change
process. Acknowledging
and working with these internal conflicts make
change more likely.
Examples of ambivalence:
-
I want to be in good shape
and I hate to exercise.
-
I want to lose weight and I
don’t want to stop eating for comfort.
-
I want to recover from this
eating disorder and I don’t want to gain
weight.
Often a client has not made a connection yet
between the conflicting beliefs, desires and
behaviors. It
is as if the part of the person that wants the
positive outcome is not in communication with the
part that is not willing to do the new behavior.
It may be tempting when you hear ambivalence in your
client to jump in and support the part that wants to
change. It
is not your job to hand the client a solution
to the internal conflict.
As a matter of fact, if you do, you will
likely encounter resistance.
The resistant side will become stronger.
How to avoid this? Slow down when you notice
these internal conflicts and bring them up with the
client. You
can work with the discrepancies you hear between
goals and behavior, and you and your client can look
together for areas of flexibility.
The most respectful and effective way to begin is to
mirror what you hear, possibly with a tone of
curiosity. “Oh,
so you really want to have better blood sugar
control. You also love good food and that it ruins
the experience of a meal when you measure your
portions. Is
that the way it is, or did I miss something?”
You are most likely to get
cooperation in this exploration if you ask
permission. For
example, once a discrepancy comes up, you could say,
“This sounds important and maybe even a reason you
feel so stuck. Would
you be willing to take a look at this together?”
Holding ambivalence is not easy
and takes shifting to a different perspective.
If you observe closely, you may notice the
client staring off into space or blinking, all signs
that a shift may be happening. Allow time for this
rather than jumping in with your suggestions.
Working with conflicting
intentions once they come up and you have agreement
to work on them:
Unpack some of what is
behind the initial conflicting statements. (See Tip
#20, available in the Practice
Workbook, Vol 1.) For
instance, in the example above, you may discover
that the client knows she will have more energy and
very likely live longer and maybe see that wonderful
grandson of hers graduate from high school if her
blood sugars are better controlled. You could also
ask some open-ended questions about her enjoyment of
food. During this open, nonjudgmental exploration,
most clients will discover some flexibility they had
not seen yet or will generate some solutions on
their own. This is because when someone is locked
into a conflict (whether internal or external),
curiosity and creativity are absent. Your invitation
to explore without judgment allows untangling of the
knots and vision to see a way out.
The fun part for you is that you need only
focus on the process of exploration. The client does
most of the work of coming up with solutions. You
may offer a few here and there, but it’s amazing
how often this is not necessary. The best solutions
come from the client because she knows her life and
circumstance much better than you do.
Expect that some clients
will not accept their ambivalence or not even be
able to see it, though it is obvious to you.
They are not ready for that leap. They are in
the early stages of the change process. Offer to
revisit it at a later time.
Finally, a word about you:
It may be uncomfortable to
be in the presence of a client holding conflicting
intentions. Ask
yourself what about it makes it so
uncomfortable. Is
it pressure to “fix it,” to make the client
change? If
so, remind yourself that your job does not include
making people change, only facilitating change when
clients are ready.
You will find more support in these Tips: #12, Power of
Acceptance; #19; How a Meditation
Practice Aids Our Work; (all available in the Practice
Workbook, Vol 1) and #26, Slowing Down
(available in
Practice
Workbook, Vol. 2).
Back
to list of Tips
Tip
#56 Effective Use of Handouts
The greatest good you can do for another
is not just to share your riches,
but to reveal to him his own.
Benjamin Disraeli
The mind is not a vessel to be filled
but a fire
to be kindled.
Plutarch
Supplemental materials can complement and support what you communicate to a client. It may be a
simple one-page sheet with food lists or a more
comprehensive booklet that reinforces your main points
about the client’s condition or diet recommendations.
Forms or booklets can also help the client to
monitor her food intake, food triggers, and appetite.
A distinct benefit
of these take-home materials is to aid a client’s
memory. In
addition, you may not get to all the details in a
session and rely on take-home materials to fill in the
gaps. There are a
few disadvantages of relying on handouts.
They can detract from your focus on this
client’s unique needs.
They may also give you the mistaken impression
that you have finished your job, that the client has
accepted the information in the handouts and will follow
the recommendations.
Of course, materials need to fit the language, education
level and culture of your client, but the most wonderful
handouts will be useful only when embedded in a
respectful counseling process. These same processes can
be used for all
the resources you offer the client.
These may include Web sites, classes, support
groups, and video and audio presentations. When you take
a minute or two to find out your client’s learning
style and readiness, you will be most effective.
Just as important, you will demonstrate respect,
and the client will more likely use the materials.
Integrating handouts effectively
- Ask
what types of
materials and processes work best for this
particular client.
“Are you the kind of person who likes to
have papers to refer to when you get home?” or
“Some of my clients find this booklet handy to
have at home. Some
people prefer I suggest Web sites, and others like
to find books in the library.
What is your style?” or
“Would you like me to go over what is in
this booklet or do you like to read things on your
own and then come back and ask questions later?”
- Ask
your client about each handout before you give
it. For example, “I have a handy sheet that has
all these foods listed on it. Would this be useful
to you?”
- Suggest
the client take
notes if it would be useful to her. “We are
talking about a lot of different things here. Would
it be helpful for you to take notes or would you
like me to jot down the main points?” Those in
private practice may want to have notepads printed
with their name and contact information.
- Whenever
you can, link
your materials to specific things the client has
asked you for. A
client who complains she has little time to prepare
meals may be ready for your handout on simple meal
ideas or on how to choose healthy take-out foods.
Ask her which she would be most interested
in. A
client who talks of feeling alone with her diagnosis
may be ready to hear about a support group.
- At
the end of a session, ask
the client if more is needed.
“Let’s look back at what we covered today
and what materials you have.
Is there more that we have missed? What will
you need to have at home to make these changes we
talked about?”
- If you are relying on a handout to cover material
that you didn’t have time to cover, make this
clear to the client. You might also ask whether the
client wants the handout now or would prefer to wait
until another session when you have time to review
it together. Even if most accept the materials, by
asking you are empowering
clients to take charge of the process.
- Finally,
attend to
your client as you offer the material.
Maintain eye contact and observe body
language. If
you notice reluctance, ask again if she is
interested or needs something else from you.
Back
to list of Tips
Tip #57
Steady Clients Who Aren’t Making Changes
Behind every success is
a succession of failures.
Rick
Beneteau
Discoveries are often made by not
following instructions, by going off the
main road,
by trying the untried.
Frank Tyger
Laura Glenz, RD, of
New York
, wrote to ask what to do when a client keeps
coming back but isn’t making changes. In settings that
encourage return visits, this is a common problem.
There are several ways to approach this.
I suggest making a guess what will work with each
client and then trying it.
If it doesn’t bring results, try another
approach.
Tactics to Experiment With
A wise first step is to share
your observation that the client appears to be
stuck. Do this in a neutral tone and language. “John,
I’ve noticed that it’s been a while since you’ve
tried any new changes.”
“Kate, you seem to like coming in for these
visits, and I know you want very much to lose weight. It
seems you haven’t tried anything new recently.”
If the client expresses frustration, mirror it
back. “So
you are frustrated and feel stuck.”
Back
off entirely. It
is tempting with such a client to work harder to get him
to change. Unfortunately,
the client is already resistant to change and your
renewed pushing will only bring out more resistance.
You have little to lose by completely letting go
of working so hard. This does not mean you will give up
pointing out the discrepancy between the client’s
stated goal and what is happening.
Return to what brought the client
to your office in the first place and what remains
important. Carefully
unpack exactly what
is important about it, how important (on a scale of
1 to 10), and beliefs about whether the proposed change
will get something of value for the client. See Tip #20
(available in the Practice
Workbook, Vol 1) for more details on this process. Take plenty of time.
You and the client may have missed something the first
time. Look
for ambivalent feelings or beliefs and conflicting
desires and values. See
Tip #55 for more on working with ambivalence.
If making a change remains
important, return to exploring
confidence to make the change.
Slow down and go step by step.
See Tip #42 (available in Practice
Workbook, Vol. 2) for more details.
Be sure to check on your client’s support
system. Is
he trying to do too much with no help?
This can significantly affect confidence to
change.
Explore with the client what outcomes (Tip
#29, available in Practice
Workbook, Vol. 2) she has in mind.
Unrealistic or conflicting outcomes can keep a
person stuck.
What if the client is not ready to
change, and even admits it, but wants to keep coming to
sessions? Ask
yourself if you are willing to scale
back your expectations and continue sessions.
Clarify what you two are doing with your time together. This
time may be valuable for reminders and for support in
maintaining changes achieved so far. An occasional
session to assess the current stage of change is another
option.
Take Care of Yourself
Finally, address
your response. It
can be demoralizing to sit with a client who is not
making progress toward his goal.
It is especially hard when you can so easily see
the necessary changes.
In your frustration, it may be tempting to push
harder. If a
client isn’t ready, all this will do is increase the
client’s resistance and your frustration. Remember
that the client’s change process does not reflect on
you. Talking over the case in supervision can help you
let go of what is not in your control.
Back
to list of Tips
Tip #58
Grief in Nutrition Counseling
Tears are often the telescope
by which men see far into heaven.
Henry Ward Beecher
We ask our clients to change behavior, sometimes in
profound ways. Change
always entails loss.
For many people, the primary reason they are
not ready to change is fear of an uncomfortable
loss. The
fear may be unconscious.
Examples:
- A
diabetic will no longer be able to enjoy a meal
with no thought to the carbohydrate content.
- A
compulsive eater will lose a useful
mood-regulation process.
- A
young woman with anorexia will no longer have
this important way to feel unique or special.
As agents of health behavior
change, we are often in the position of grief
counselors. How
to aid the grieving process? The healthiest and
most effective way to lessen a loss is to
acknowledge and move through the grieving process.
It does not work to deny the loss or try to
fix it for the person experiencing the loss.
Look for it.
Notice the things that a client says she will
miss. If
the client doesn’t mention any, ask what they are.
This may be difficult at first.
It is tempting to play up the positive
aspects of change and minimize the downside.
Acknowledge
the process as loss.
This may mean bringing it up when the client
doesn’t. I
call this “preemptive empathy.”
“Wow, John, this will be a big deal for you
to let go of your steak dinners with your friends.
I suppose this will be sad for a while.”
“Judy, I hear that you really want to stop
turning to food when you are upset.
I imagine that you will then be at a loss as
to what else to do for a while.”
When you hear something that sounds like
disappointment or sadness, mirror it. “So you will
miss that really full feeling after lunch.”
Family and
friends may not acknowledge the loss or will
even deny it. “My husband is so happy I have
finally gained weight so I get my period.
He doesn’t understand how scary and sad
this is for me.” You
can explain that this is common and it doesn’t
mean that her sadness is invalid.
Tolerate
it. This
is the hard part for some professionals.
Being in the presence of someone who is
grieving (or who is experiencing any uncomfortable
feeling) is uncomfortable. You
want to fix it or make it go away. Those
of us in the helping professions tend to be
wonderfully empathetic.
It is therefore difficult to be in the
presence of someone experiencing uncomfortable
emotion without being affected yourself.
Remind yourself that your job here is not to
fix the loss, disappointment or sadness.
It is simply to witness.
Encourage
other support. Are
support groups available?
For example, some bariatric surgery programs
have support groups conducted by mental health
providers. Support
groups for the client’s condition (diabetes,
cardiac surgery, kidney disease) may provide a
holding environment for grieving.
If your client is stuck, bring up the idea of
seeing a counselor.
Take care of
yourself. Acknowledge
how hard this is on you and look for support.
Back
to list of Tips
Tip #59
A Format for Providing Advice
Change and growth take place when a person
has risked himself and dares to become
involved with experimenting with his own life.
Herbert Otto
Think about your own successful
interactions with health professionals, those times when
you asked for information and welcomed it. Likely
several things were true: First, you wanted the
information and it was just what you were ready for, no
more, no less. If it was a satisfying interaction, two
more characteristics were likely present: The
information was provided in a neutral, factual manner,
and you were given a chance to think about your reaction
and to ask follow-up questions.
This is indeed a healthy, normal health-care
education interaction.
- The
patient asks for information.
- The
health-care professional provides facts.
- The
patient takes in the facts and decides what to do
next.
What can you do to make it most likely clients will be
active participants in the interaction?
Here’s a handy format to experiment with:
•
Elicit what the client already
knows. This may save both of you precious time. Then
ask what the client wants to know right now. The
response might sound quite limited to you. You usually
have much more information than a client is ready
for. A person will hear best what he is ready to hear.
Doing this first also implies respect and encourages a
client to
take control of his health care.
•
Provide the information in a
neutral manner. It may be tempting to use imperative
language, such as “You should…” or “You have
to…”, or to
imply the client is going to follow your instructions.
“You will choose from this list of foods.” Switching
to neutral language makes it easier for the client to
hear the information and more likely he will consider
it.
See Tip #39 for more on imperatives (available in Practice
Workbook, Vol. 2)
•
Elicit the
client’s response to and interpretation of the
information. It is easy to forget this step. Keep these
questions open-ended. The client will have a response.
By asking for the response with open-ended language, you
again imply that the client is in charge and is expected
to decide how to proceed. Asking to hear the response
will promote the integration process.
Here’s an example:
- Initial
eliciting questions: “What do you know about the
effect of carbohydrate-containing foods on blood
sugar?” “What information do you need from me
about this right now?”
- Providing
neutral information: “When people eat carbohydrate
foods in these portions, their blood sugars are most
apt to be in the normal range.” “This is the
amount of pasta that provides 15 grams of
carbohydrates.”
- Eliciting
responses: “What is your response to this
information?” “What do you think of this
chart?” “What are your thoughts about all
this?”
This is a handy format when you
have little time! It pinpoints what the client wants. In
the end you may feel as if you provided very little, but
what you have provided will most likely be retained. The
next time you are about to give advice, experiment with
“elicit/provide/elicit” and see what happens.
Back
to list of Tips
Tip # 60
Open and Closed Questions
The mind is not a vessel to be filled
but a fire
to be kindled.
Plutarch
Facts are useless
if you need advice on how to use them.
Halla
All counselors ask questions. The manner in which they
are asked has a profound effect on the client. Here we
look at two types of questions, open and closed. It
is useful to be able to tell the difference and to shift
easily between them.
Closed (or
closed-ended) questions can be answered with “yes,”
“no,” a number, or a very short answer. Here are
some examples:
- How
tall are you?
- What
have your blood sugars been this week?
- What
do you eat for breakfast?
- Do
you exercise?
- What
is your favorite snack?
These have the effect of keeping
the client in a passive
role. The longer the counselor stays with this style
of questioning in a session the more passive the client
becomes.
It is easy to ask closed questions.
It takes more practice to use open questions.
Open
(or open-ended) questions request a story from the
client, not just an answer. They encourage thought. Here
are some examples:
- What
has your experience been with exercise?
- How
could you see adding some high-calcium foods?
- What
is your plan for this week?
- What
long-term consequences of diabetes concern you most?
- What
do you need from me?
These questions assume and
encourage an active role for the client in the process of changing behavior.
They will likely bring out meaning in addition to facts.
They often start with “What” or “How.”
It is useful to begin to ask some of these open
questions as soon as possible in a session to develop
rapport. They also go beyond rapport building by
forwarding the work of behavior change counseling.
Here are some more questions
to practice with. Are they open or closed? Play with
the closed ones to shift them into a more open style.
- What
is your favorite food?
- What
is your reaction to this food plan?
- Have
you thought of switching to brown rice?
- Could
you leave off the butter?
- How
are you doing with this so far?
- What
matters most to you about losing weight?
- Do
you want to control your blood sugar?
- How
about water instead of soda?
- If
you brought your lunch, what do you imagine that
would be like?
Of course in our role as nutrition
counselors we need to ask many simple, closed questions.
Learning to sprinkle
in open questions contributes to skill as a behavior
change counselor.
Back
to list of Tips
Tip #61
How to Shift Your Counseling to Mindful
Eating
The distance is nothing;
it’s only the first step that is difficult.
Marquise du Deffand
Every object, every being,
is a jar full of delight.
Be a connoisseur.
Rumi
Mindful eating means approaching feeding oneself
with pleasure being primary and letting go of
judgments. It presumes both acceptance and
awareness. Acceptance
includes embracing one’s needs and desires and the
inherent rightness of the feeding process. Awareness
includes attention to physical hunger and satiety
clues. Some people call this intuitive eating.
During a nutrition counseling
session, there may be clues that a client is not
eating mindfully.
- Not
remembering what was eaten.
- Binge
eating or ignoring internal cues to eat.
- Rapid
eating.
- Guilt
over eating. Calling foods “good” or
“bad.” Calling herself names.
- Asking
you to tell her exactly what to eat.
- Judgments
about food and the process of eating.
- Attachment
to the outcome (usually body weight).
You may notice these barriers
to normal eating and believe the client would
benefit from addressing them. How can you shift gears
and get the client’s agreement to work on this?
Targeting your responses to the client’s stage of
change is useful here.
A client in the precontemplation
stage may deny a problem with how she approaches
feeding
herself. The client doesn’t notice that her eating
is largely mindless. She sees no need to approach
eating in a different manner.
With this client, mirror
what you hear, especially the words that you pick up
as expressing mindlessness. “So, you tend to
ignore your appetite and wait until it’s
lunchtime.” Invite
attention to appetite, satiety, taste, texture,
etc. “What do you imagine would happen if a few
times during the morning you asked yourself if you
were ready to eat yet?”
For more on mirroring, see Tip #
6 (available in the Practice
Workbook, Vol 1)
The contemplation
stage is marked by some awareness of mindless
eating and a realization that it is harmful. The
client may have little idea of other options. So
your stance includes mirroring what you hear and
offering perspective and ideas. “Oh, so there are
times you eat in response to appetite and others
when you eat for other reasons?”
“Do you know what mindful eating is?
Would you like to hear more about it?”
“What would be your ideal way to feed
yourself?” You might include your beliefs about
the role of mindful eating in a particular
client’s situation and invite thought and
discussion with open-ended questions. “I believe
that it is incompatible to focus on weight loss and
easeful/mindful eating at the same time.” “What
is your belief about what would happen if you mostly
ate when you were hungry and stopped when you were
satisfied?” For more on open-ended questions, see
Tip # 60. For more on stating what you know to
be true, see Tip #
50 (available in Practice
Workbook, Vol. 2).
With a client in these earlier
stages, you will likely need to let go of your focus
on mindful eating. Staying client-centered means focusing on what matters to the client, not to
you. This does not mean that you will drop it
completely. If you continue to see examples of
mindless eating that interfere with the client’s
stated goals, you can toss in some mirroring again.
The seeds you sow may take hold someday. Be patient.
For more on staying client-centered, see Tip #
20 (available in the Practice
Workbook, Vol 1).
A client in preparation
wants to eat more mindfully. He believes that if he
eats mindfully most of the time he will feel
physically (and maybe spiritually and emotionally)
better. This client does not need much persuading
and mostly needs specific steps and support. You can
encourage observation of the current feeding process
to learn from it and suggest experiments with
mindful eating. You can gently point out the
judgment words when you hear them and suggest
letting them go. The client will notice at least
some triggers for mindless eating. You can encourage
more exploration of these.
You will know your client is in
the action stage when she is doing mindful eating at times and bringing
observations back to you.
She may ask for ideas for more shifts to
make. She
will be looking for and trying out new,
nonjudgmental thoughts. She will be searching for
triggers for mindless eating and other ways to cope.
Here you are primarily a consultant. You might help
brainstorm nonjudgmental thoughts and coping
techniques for stress. You will continue to
encourage an experimental mind-set, going back to
the drawing board at times. You might encourage
other mindfulness practices such as meditation or
yoga. You will also remind her that no one is
perfect and that normal eating includes some
mindless eating.
For more on experimentation, see Tip #
3 (available in the Practice
Workbook, Vol 1).
A client in maintenance is mostly eating mindfully. Some tweaking of the
client’s life may be needed for a more easeful
process. This
client has ways to cope with most triggers to eat
mindlessly. Overwhelming stress still poses a
risk. Here you can work on preparation for relapse
and offer to be available if she gets off track.
For more on supportive environments, see Tip
#8 (available in the Practice
Workbook, Vol 1).
Find more resources on Mindful Eating at www.tcme.org.
Back
to list of Tips
Tip #62
Working With Family Members of Clients
Life
is not holding a good hand;
life is playing a poor hand well.
Danish proverb
The most important single ingredient in
the formula of success is knowing how
to get along
with people.
Theodore Roosevelt
Your
clients learned eating habits and food beliefs in their
original families. And most clients now live in families
that profoundly affect how they feed themselves. In
addition, you often
see glimpses of family dynamics in your sessions. You
don’t have the (extensive) training that family
therapists have and working with family process is not
your job on the team. So what to do when family dynamics
intrude and make your job harder?
Here are some examples of what you
might see and ideas of how to handle it:
A family
member calls to set up an appointment for an adult
client. Find out why this person has called rather than
the client. The client may not be ready for nutrition
counseling, and the family member is trying to force it.
Ask if this was the client’s idea or the caller’s.
There may be a good reason, such as the client is not
able to make calls from work and asked his wife to make
the call. If you sense a lack of commitment, you could
request that the client call to set up the appointment. Tip
#44, Dealing With the Expectations of Others (available
in Practice
Workbook, Vol. 2), may
be useful, too.)
A parent
of a teen calls between sessions.
The parent may want to tell you in detail of
behaviors seen at home. I find it useful to set ground
rules before hearing anything from the parent.
For example, “I can tell you are very concerned
about your daughter and want me to have all the
information I need to help her. I would be glad to hear
anything you think may be useful. I will share what you
tell me with your daughter at our next session.
I suggest you tell her you have called so she
won’t be surprised.” When
the parent demands
that I not tell the teen of the call or of some specific
information, I point out that this would not be fair to
either me or the teen. I say that it is up to the parent
to decide what to share knowing that I will fill in the
teen. If the parent is asking you for information about
what happens in sessions, remind the parent of the value
of confidentiality for the teen and reassure the parent
that you will tell her about any dangerous behavior. See Tip
#45, Professional Confidentiality (available in Practice
Workbook, Vol. 2).
A family
member comes into a session and then takes over or
speaks for the client.
These are very difficult situations.
It takes practice to handle them smoothly and
with respect for everyone. It is useful to catch it
early. For
example, if a mother assumes she will come into a
session with a 17-year-old, you could set the stage
either on the phone or as you greet them. “What I do
in these situations is to meet with both of you for a
few minutes to gather basic information.
Then I will meet with Lisa alone for a while and
before the end we will ask you to come back in.”
It is harder to address once the dynamic has
begun. For
example, you are meeting with John, who is the client,
and his wife, Sally. John says very little, and Sally
tells you details about how John eats and what he should
do. The sooner you catch this and address it the better.
It may feel like breaking in and changing the subject,
but it will be worth it. “Sally, I am glad you came
with John today since you clearly care a lot about him
and are very involved in the family eating decisions. In
order to best help John get his cholesterol level down,
I need some information that only he can give me.”
A client reports family
members who sabotage change efforts. If your client
is motivated to change and not using the sabotage as an
excuse, you could offer to coach him to assert his needs
with the family members.
If he agrees, share the steps of assertiveness in
Tip #48 (available in Practice
Workbook, Vol. 2).
Parents of younger children who
want you to “fix”
their child. Whether the issue is obesity or picky
eating, this is a recipe for failure. Children do not
change their eating behaviors in the deliberate ways
that adults can. Educating
or counseling them will rarely lead to change. Parents
are the only ones with sufficient influence to affect
the child’s behavior. If you choose to take on these
cases, it is most effective to work with the parents
alone. Ellyn Satter’s resources provide guidance for
you with this specialized work. (www.ellynsatter.com
)
Many of these tricky family
dynamics involve the process of triangulation. Review
Tip #23 (available in the Practice
Workbook, Vol 1) for more on triangulation and how to handle it.
If you work with eating disorders, I highly recommend
the work of Chris Haltom, PhD, www.edsurvivalguide.com.
She has a free newsletter and many articles for
families of those with eating disorders.
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Tip #63
Affirming
Perhaps once in a hundred years a person
may be ruined by excessive praise,
but surely once every minute
someone dies inside for lack of it.
Cecil G. Osborne
Behind every difficult person or situation
is a blessing just waiting to be revealed.
Cheryl Richardson
Affirming in a counseling relationship is a
type of reflection. You selectively reflect back positive thoughts, words and actions as a way of supporting positive change.
Some examples:
• “That’s a great idea.” Throw this one in when brainstorming food
or exercise ideas.
• “I can see you already have a lot of resources and strengths.” This helps the client see what she already has in place.
• “So, you’re the kind of person who goes ahead and does something once you’ve decided to.” This affirms a process the client uses elsewhere that can be applied to health behavior changes.
• “Thank you for coming in today. I know it was not your idea to see me and I appreciate it.” This one fits when you know the client is reluctant.
• “You are dealing with a lot right now. Anyone would have trouble coping with all that.” This validates the client’s experience.
What affirming does:
• Builds rapport
• Allows client to feel heard and appreciated
• Encourages client to further explore the change process
• Builds confidence
When you need to set limits with your client, it is useful to
affirm first. For example: “That is wonderful that you can ask for help when you need it, and I am glad you find my voice on the phone supportive. I have a policy of no more than two phone calls between sessions.” This works with family members, too. “I am so glad you came along with your husband today because you clearly play a vital role in choosing what foods are in the house. Now, I need to speak with just him for a while to find out more what this means to him. I appreciate your being willing to listen in quietly. I’ll ask for your input in a few minutes.”
Cautions:
Overly enthusiastic affirming can border on cheerleading. Simply worded, calm, affirming statements are stronger than you may imagine. There is no need to add extra energy to your voice or to add praise or cheerleading statements, such as “Good for you,” “Keep it up,” “I’m proud of you,” “That’s great that you followed your plan for a whole week” (with a big smile). Staying more neutral will keep the client in charge. For example: “So, you’ve followed this plan for a week. You hadn’t been very confident you could do that. How are you feeling now?” Some clients are people-pleasers and will respond to praise by trying to elicit more praise from you. Reflecting back neutral affirmations minimizes this risk.
There is a potential trap of affirming the change side so much that the client goes into defending no change and you find yourself arguing. If this happens, you can quickly even it out by reflecting back both sides (see
Tip
#55, Ambivalence).
Practice:
• Look for and affirm expressions of confidence: “I know I can at least ask for dressing on the side.” Affirm it: “So that’s something you know you can do.”
• Attune your attention to client strengths and efforts even if they have not yielded results yet. “You are really observing all the steps that happen before a binge.”
• Take the time to affirm changes that have already been made, discoveries, any progress. Don’t assume the client notices and celebrates them.
As with all types of mirroring, affirming can seem unnecessary or redundant. If you have not been affirming much, it will feel odd at first. Try it as an experiment (see Tip
#3, available in the Practice
Workbook, Vol 1). Throw in a few affirmations in your next few sessions and observe the results.
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Tip #64
The Power of “And”
Instead of cursing the darkness,
bring in the light.
Carolyn Costin
Acceptance of what has happened is the first step
to overcoming the consequences of any misfortune.
William James
The word “but”
comes up many times in nutrition counseling sessions.
A client may say:
- “I
want to lose weight in a healthy way, but I hate my
body the way it is now and I want to lose it
fast.”
- “That
is a good idea, but I don’t have the time.”
- “I
did really well for a few days, but then I blew
it.”
You might say:
- “That’s
great that you added two crackers to your snack, but
you need to do more if you want to gain as much
weight as the doctor wants.”
- “I’ll
work with you on diet changes, but you will still
need to take the medication the doctor gave you.”
Read these examples carefully. Notice that “but”
negates everything said before it. The conflict
between the two ideas is accentuated, and this leads to
being stuck. The feeling
is of “a rock and a hard place.” Nothing is moving.
Here’s a simple language
shift that helps both you and your client gain
elbowroom for creative approaches to change. When
“buts” appear in your client’s language, they
signal ambivalence to change. Acknowledging and working with
ambivalence is one of the most powerful processes in
counseling. (For more on working with ambivalence see Tip #55) Simply
substituting the word, “and” for “but” shifts to
acceptance of ambivalence.
Shift your stance by giving these responses to the
client examples above:
- “I
hear that you are very distressed about your body
the way it is now and
you also believe it’s a good idea to approach
weight loss in a slow and steady way.”
- “You
do have a busy life. It’s not easy to fit in new
things. And
I hear you saying that you believe my idea would
work if you found a way to fit it in.”
- “So
you had some days when you accomplished most of your
goals and
some days when things got in the way. Would you be
willing to take a look at both those types of days
to see what we can learn?”
Notice how the use of “and”
acknowledges both parts of the split. By shifting your
stance (and the tone of the session) from resistance
to acknowledging ambivalence, you find a space to be creative.
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Tip #65
The Righting Reflex and How It Gets Us in Trouble
When you relax,
you can make miracles.
Tan
Dun
The art of being wise is
the art of
knowing what to overlook.
William
James
Human beings have a desire to set
things right. When we see a picture hung crookedly, we
feel compelled to level it. Whenever we notice a
discrepancy between how things are and how we believe
they should be, we try to reduce that discrepancy. As
nutrition professionals, we are trained to pick out the
discrepancies between what our clients tell us they are
doing and what would be best for their health.
This is an integral part of our assessment. What
happens next determines how effective we will be.
Our clients are not inanimate
objects like pictures are. They are multifaceted beings
with conflicting desires, beliefs, preferences and
fears. These factors combine at the moment we encounter
a client to determine readiness to make changes. If the
client is ready to change, our suggestions will likely
be smoothly met with appreciation and action.
Many clients are not ready.
They are deeply ambivalent.
They have a complex mix of pros and cons for
making the changes we can so easily see are needed.
In response to our righting reflex,
we, of course, advise or try to persuade the client to
make the change. This
places us firmly on the change side of the ambivalence.
The client then takes the other side, the side that is
not ready to change. The client has then abandoned the
change side (since we are taking responsibility for
that) and advocates for the side of no-change. This is
when we hear “yes, but.” Our natural tendency is to
continue to try to right the situation and argue harder.
This causes the client to take the opposite side more
strongly. The more the client states the no-change side,
the stronger those arguments feel to the client and the
resistance to change strengthens.
So, when you sense your righting
reflex, first find out if the client is ready for your
advice. See Tips
#47, Choice (available in Practice
Workbook, Vol. 2) and #59,
A Format for Providing Advice.) If
the client is not in at least the contemplative stage of
change, your next step is to silently acknowledge the
righting reflex and decide to not act on it. This takes
a deliberate holding back since responding by righting
the discrepancy is natural. It may help to take a deep
breath or to remind yourself that there will be a time
to give your wonderful advice when it will more likely
be heard.
It is the client’s job to resolve
the ambivalence, not yours. When you jump into one side
of the client’s conflict, it does not help the client
with this process. (For more on how to effectively
proceed in the face of ambivalence, see Tip
#55, Ambivalence.)
____________
This Tip describes one of the
fundamental concepts in the work of William R. Miller
& Stephen Rollnick;
Motivational
Interviewing, 2nd Ed. Guildford Press,
2002. Pages 20 – 22.
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Tip # 66 What You
Don't Know Can Help You
Faith means living with uncertainty -
feeling your way through life,
letting your heart guide you
like a lantern in the dark.
Dan Millman
Listening, really listening, is tough and grinding work,
often humbling, sometimes distasteful.
It's a fairly sure bet that you won't like
the lion's
share of what you hear.
Bob Waterman
There was once an eager young man
who wanted to learn from a master.
The master said they would begin by having tea
together. The young man was annoyed and impatient to
begin his lessons, but sighed and tolerated the old man.
The master poured tea into the student’s cup
and kept pouring long after it was full.
As tea spilled on the young man, he became angry
and asked why the master was doing such a stupid thing.
He said, “You are too full.
I cannot teach you anything when you are so full
of yourself and the skills you have now.
When you come to me empty enough I will begin to
teach you.”
We are highly educated and trained
professionals. We know a lot about nutrition and about
our chosen specialty. For those of us in practice a long
time, it is easy to get caught
up in our expertise. Yet when we focus on what we
know, it is easy to miss important things.
As we sit with a client we review
in our heads what we know about this person and her
condition. We
know what information we are missing and need from the
client and we ask questions
to fill those holes.
Once we get enough information, it’s time to
proceed to education. We
are off and running. It is easy at this point in the
session to shut off your curiosity. Continue to focus on
what you don’t
know. I sometimes call this stance the “Columbo”
stance, named for the Peter Falk detective character who
always acted dumb and, as a result learned more.
Maintaining this stance helps you
stay client-centered. You are attuned to what is true for this client. An
interesting experiment is to approach a client session
with a stance of “I don’t have a clue.” See how
long you can hold on to it.
Staying focused on what we know
also contributes to burnout.
Dipping into a clueless stance periodically throughout
our work allows us a break. We work less hard and end
our day less exhausted.
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