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:
2008 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 # 67 Effective Review of
Food Records (1/1/08)
Tip # 68 Hope (2/1/08)
Tip # 69 Change Talk (3/1/08)
Tip # 70 Borderline Personality
Tip # 71 How to Discuss (Or Not) Our
Size With Clients (5/1/08)
Tip # 72 Summarizing (6/1/08)
Tip # 73 Recording Sessions for
Tip # 74 To Weight Or Not To Weight
Tip # 75 Ending Treatment
Tip # 76 Scaling Questions
Tip # 77 Professional Working
Tip # 78 Understanding Trauma
Review of Food Records
People deal too much with the negative, with what is wrong...
Why not try and see positive things, to just touch
things and make them bloom?
Thich Nhat Hanh
Acceptance of what has happened is the first step
to overcoming the consequences of any misfortune.
We are often in the position of reviewing the food
and activity records our clients have kept. This Tip
addresses how to conduct this review in a manner most valuable to the client.
You already know that effective feedback is
descriptive and specific to the behaviors that the
client has agreed will help achieve her health goals
in a step-by-step manner and that it includes praise
as well as suggestions for change. This Tip
addresses the subtle ways in which language affects
how feedback is received.
How the client hears or reads your comments may be
completely different from your intention. When a
client takes your comments differently than you
intended, it does not mean either of you is wrong.
You simply each look at it in your own way. We can
choose to adjust and hone our feedback to best serve the client.
What about food records makes the skill of your
response so important?
For some clients, this process
reminds them of school and being
graded. Even before you make your comments,
criticism pops up in the client’s head. It’s
likely these internal criticisms are part of what
has held the client back from change. When your
feedback is even a little judgmental, this
reinforces the client’s self-criticism, keeping
the client stuck.
Revealing what and how we eat
is quite personal. What the records reveal may be
embarrassing. The client will feel shame even before you give any feedback.
When experiencing shame, a person is unable to take in much of what is said. This
does not mean that you should not ask your client to
reveal, it just shows how important your care and
respect are to your client.
How to maximize your
the client that it is not
about being judged. Saying this once may not
be enough. Keep referring to the records as
“useful information,” “notes of your experiments” “to help us observe your process.” This
wording frames the records as primarily the
client’s (not yours) and to be used by the
client to move forward.
offering the feedback in individual sessions,
use the Elicit/Provide/Elicit format described in Tip
permission before offering advice. “Would you
like to know what I see here?” When advice is
provided in a neutral manner and immediately
followed with a question such as “What do you
make of that?” or “What are your thoughts
here?” you are showing respect for the
You are saying that the client’s
response to your feedback is important in the
a client takes all your comments as criticism no
matter how hard you try to keep it neutral,
likely this is what she does to herself. You can
more useful way to use the records by
repeatedly taking a neutral, observational
stance. In a group class, if your program
includes a cognitive restructuring segment, ask
the participants to note these negative thoughts
and save them for that week. When they make
self-affirming or other useful comments (“That
worked well, I want to try that again.” “Now
I see that when I get really hungry, I always
overeat.”) reflect back your belief that these
self-comments are useful.
When a client is ready, word your
comments to focus on the chain of events that
led to eating in ways he is working to change.
Keep the tone on simple observation. “We can
have opinions on this later.
Right now let’s just look and see what
we can learn from what happened.” “Let’s
let go of the judgments for now. So what
happened next?” You may find a “why”
question occurring to you, such as “Why did
you eat that snack?” Your intention may be to
direct your client’s attention to the triggers
for unplanned or non-hunger eating.
Unfortunately the word “why” is almost
always taken as a criticism, and when
criticized, we naturally get defensive. (See Tip
#17, available in the Practice
Workbook, Vol 1.) If you are conducting a
group class, once you have covered the week on
behavioral chains, you can ask if the
participants would like to apply that process to
their example. Your comments can focus them on
the process (i.e., asking
what happened first, what
happened next, etc.) rather than the result
(i.e., I over-ate) and therefore model for the
client a more useful stance than simple
Some notes on written feedback in group classes:
If you write the comments
by hand, of course they will be more visible if
in a different color from the client’s words. For
some, a red pen will remind them of school. Choose
another, more neutral color.
Be sure to keep
a record of your feedback to each participant,
so you can move your comments along in concert with
the person’s change process.
You can encourage the group
members to begin the process of learning from their
records before they hand them in by adding their own comments. This
is tricky since from some you will get mostly very
negative comments. (“Stupid!” “Why the heck
did I do that.” “There I go again.”)
When you get to this part of the course,
suggest these clients go back and ask themselves if
these self-comments are the most effective ones they
can think of.
Ask for feedback on your
People vary greatly in what is
of most value to them. Does this client want
specific ideas? (“Try low-fat milk here
instead.” “How about parking farther from the
store?”) Or are they quite capable of
brainstorming ideas and benefit most from pats on
the back for baby steps. (“Great
job this week on your walking!” “You’re making
wonderful progress with restaurant choices.”) You
may be able to pick up the client’s
preferences, but there is no reason not to ask!
“How’s this process going?” “I just
made some suggestions, is that the kind of thing you
want from me?” “Many people find it useful when
their progress is praised.
Is this helpful to you?”
In a group where you mostly
provide the individual feedback in writing, add a
request the first time you pass out the record
forms. “I don’t know what kind of comments will
be most helpful to each of you. Please tell me which
of my comments help you and which don’t.” Repeat this request more times a few weeks apart.
When you do get feedback, accept it with care and respect even if you disagree or don’t
it back so the client knows you heard it and then
ask for assistance in honing your comments. “I
hear that to you my comments feel trite. I want to
help you in every way I can. Which of my comments have
been useful? Is there more you need from me?” By
not getting defensive, you are modeling for your
clients a healthy process that leads to real change.
to list of Tips
Tip #68 Hope
Never deprive someone of hope;
it might be all they have.
H. Jackson Brown Jr.
A friend is someone who knows the song
heart and can sing it back to you
when you have forgotten the words.
It is not unusual for your clients to feel hopeless at
times. You can choose to sit
with them in their despair while not losing hope
the hope for the both of you is valuable, especially for
clients with eating disorders or frustrating medical
you have experienced others recovering or finding ways
to live with their condition, you can hold that memory
for your other clients.
It’s important to acknowledge
the client’s feelings while seeing the situation
differently and being more optimistic.
When you indeed are more hopeful than your client
is in the moment, your job is not to convince him, but
simply to hold the hope.
There may be a place for you to inform the client
that you will do this for him.
“I hear you that you feel hopeless right now.
It feels like you will never get used to this
condition. I have seen your strength and have hope for
What if you
aren’t optimistic for your client?
You can still guide the work to some goal that
both of you do have some hope for.
This would mean reframing the work. (See Tip #10
for more on reframing, available in the Practice
For example, clients with metabolic conditions
will never recover full health and will always have to
adjust their lifestyle to treat the condition.
What is the hope then?
Perhaps it will be that they will maintain a
certain degree of function and health. You are not doing
the reframing; you offer frames that the client can then
choose whether to pick up.
Some clients appear to be unrealistically hopeful. For
example, a weight management client may expect faster
weight loss than is possible without severe restriction,
or may hope for a lower weight than she has been since
childhood. It may be tempting to jump in with your
opinion. Unfortunately, you will either get an argument
or cause the client to lose hope and motivation to
change. It is more effective to first ask for the
client’s experience with weight loss or about weight
history. You could then ask for a clarification of the
client’s hopes and expectations. When you continue
this line of discussion with open-ended questions and
reflections, it is more likely the client will adjust
her expectations and hopes.
goals effects hope. When hope is only for weight
loss, for example, discouragement is inevitable.
You can guide clients to look at a broader range
of outcomes such as a more relaxed, healthy relationship
with food, or eating a minimum of healthy foods, or
making slow improvements in eating habits. (See
Tip #29, Working With Outcomes, available in Practice
Workbook, Vol. 2)
In our field, we see clients who hold a sense of self that is deeply embedded in a dream of a certain body.
Identity tied in with body is normal. What is not
normal is when this becomes a preoccupation or when the
person hopes to improve the whole sense of self by
changing the body. When we observe this in a client,
it’s time to acknowledge the limits of your training
and refer the client for therapy if that is not already
not the same as
are indeed helpless in the face of some things: cancer,
diabetes, metabolic weaknesses, and genetically
determined physical attributes such as height, frame
size. There is always some hope to be found in any
one finds it, the way becomes clear. It
is a healthy process to acknowledge helplessness
(something you can’t change). Grieving loss is an
integral part of a healthy process of maintaining hope.
#58, Grief in Nutrition Counseling.)
Giving up on one goal can at times feel like
giving up hope as well.
However, it only means losing touch with it
briefly before a new hope emerges.
It is easier to go through this process with
someone else. That
someone else can hold the hope and then give it back.
The strategies of Motivational
Interviewing have the effect of increasing hope when
a client feels hopeless.
For example, when exploring a client’s
confidence to make a specific change on a scale of 1 to
10, an answer of “3” indicates low confidence. By
then asking what makes it a “3” and not a “1,”
the client will focus on skills, strengths and resources
that already exist.
A common process that leads to hopelessness is the
desire to change, then a focus on the reasons to not
change or how it will be difficult. The next step is
often shutting down and no longer thinking about it.
When this happens over and over, hopelessness sets in.
By thoughtfully working
though ambivalence, you help your clients move
toward change. Your patience and curiosity in staying with the process
support the client’s hope. (See Tip
For clients who are in early stages of change, using hypothetical
questions keeps a door open for change and increases
hope. “Let’s imagine for a moment that you did begin
walking around your neighborhood a few days a week. How
do you imagine you would feel? And how would you go
about it to be successful?” “Just suppose you did do
some more cooking at home. What might be some of the
to list of Tips
Motivation is a fire from within.
If someone else tries to light that fire under you,
chances are it will burn very briefly.
Celebrate what you want to see more of.
A central concept in Motivational Interviewing is that
clients use specific language that tells you where they are
in the process of changing behaviors.
You can practice listening for these statements in
your sessions. They occur when clients express their
desire, ability, reasons and need to change.
When they are ready, they will also share their
commitment or that they have already made a change.
Change language that you hear in the contemplation and preparation stages of change is especially
important to notice and work with. It is in this stage that
you have an opportunity to guide your clients forward. The
acronym DARN helps you to remember the four types of early
Statements about preference for change.
“I want to…”
“I would like to…”
Statements about ability.
“I might be able to…”
Specific arguments for change.
Statements about feeling obliged.
“I ought to…”
“I really should…”
“I have to…”
When your client is in contemplation
and action stages of change you will hear the final two
types of change talk.
about likely change.
“I am going to…”
Taking Steps: Statements
about action taken.
can train yourself to pick up key words and highlight
them for your client. Begin searching for these statements
and you will be amazed how many you will hear.
Reflect them back when you hear them to reinforce the
change process. (For more on how to reflect, see Tip #6,
Mirroring, available in the Practice
Many clients will say change talk
easily. If you
aren’t hearing much, these questions
will elicit the change thoughts that are in the client.
“What do you want, like, wish, hope…”
“What is possible? What could you do? What are you
able to do?”
“What would be the benefits? What would get better?”
“How important is this change? How much do you need to
“What are you going to do? What will you do?”
Steps: “What have you done so far? How are you
doing it differently now?”
For more on working with change talk, I
recommend Motivational Interviewing in Health Care,
Rollnick, Miller and
to list of Tips
I am often asked to explain the
phenomenon of borderline personality. Those who work with
clients with eating disorders or with the mentally ill or
substance abusers encounter it frequently.
Personality disorders are in a different category than other mental illnesses. They are enduring
patterns of experience and behavior that affect cognition,
mood, relationships and impulse control. They are not
considered biological and do not generally respond to
are 10 personality disorders.
Others you may have heard of are narcissistic,
antisocial and avoidant. Borderline is one that nutrition
professionals find particularly challenging.
It is not
your job to diagnose any mental illness or personality
disorder. However, it can be useful to understand them.
Here is a summary of the diagnostic criteria:
A pervasive pattern of instability in
relationships, self-image and mood and significant
impulsivity with at least five of these characteristics:
efforts to avoid real or imagined abandonment
and intense interpersonal relationships alternating
between extremes of idealization and devaluation
unstable self-image or sense of self
that is potentially self-damaging
behavior, gestures or threats of self-mutilating
instability lasting a few hours
feelings of emptiness
thoughts or dissociation when stressed
A simple way to understand this kind of
person is to think of a 2- to 3-year-old.
It is normal at that age to have a poorly formed
sense of self and of separation (border) between self and
example, when a toddler is not getting what he wants, he may
act very angry and say, “You are a bad mommy.” A while
later, when all is well, he may sit on mommy’s lap and
say, “I love you, mommy.”
We know that the mother has not changed; the
child’s internal experience has changed. Most children
grow out of this phase and are able eventually to hold a
relatively constant sense of self in the face of
uncomfortable internal experience or stress.
Someone with a borderline personality has a poorly
developed sense of self and so emotions do not appear to
them to come from inside but to originate in people around
Typical things you might see:
client swings between saying you are the very best
dietitian ever to being the worst.
client sees one team member as “all good” and
another as “all bad.”
These may shift from one team member to another
at different times. This is called splitting.
client will express what seems to be an inappropriately
strong fear of being abandoned by you or someone else.
client is unusually friendly and seems to want to know
all about you.
client’s mood or personality seems surprisingly
different from one session to another.
client will call extremely distressed and insist on
needing to see you or talk to you. A few hours or a day
later, the client will be fine and may have even
forgotten the distress.
If you are working with a client who
seems to fit these criteria and the client is seeing a
therapist, ask the therapist what the diagnosis is.
Ask whether the specific signs or behaviors you are
seeing are borderline characteristics.
How to handle these clients:
all professional boundaries carefully. This
includes self-disclosure, answering personal questions,
interacting with clients outside your office, beginning and
ending sessions on time, and expecting payment on time.
These clients will push these boundaries over and
over. Again, think of your client as a toddler.
We all know that toddlers push limits. They thrive
when we set boundaries and stick with them, but will never
thank us. (For more on maintaining boundaries see Tips # 1,
18 and 21, available in the Practice
It is extremely important when working
with such clients to keep
in close contact with all the other team members,
especially since splitting is likely. Think of the work that
parents of young children need to do to avoid getting
manipulated. It is easy to fall into distrusting another
team member because of the way these clients may split the
team member off. Acknowledging with the team the client’s
tendency to split goes a long way. Check out carefully
anything you hear from the client that another team member
Take care of yourself!
These clients can be extremely
trying. They can drain you of energy and will likely
never provide the gratification other clients do. Getting
supervision for these clients is a good idea for their sake
as well as yours.
to list of Tips
Tip # 71 How to Discuss (Or Not) Our
Size With Clients
You can get everything in life you want,
if you’ll just help enough other people get what they
When you blame others,
you give up your power to change.
You may have heard of clients choosing a nutritionist or
leaving one because
of her size. Adina Pearson, RD, sent me this example:
“Recently I had an anorexic young client whose excuse for
not wanting to keep her follow-ups with me is that I (her
RD) am skinny and it’s not fair that ‘she is telling me
to get help.’ In the future, should I ‘break the
ice’ about my
size and bring it up sooner? I could acknowledge that I am
small but that the difference is in my relationship to food,
outlook etc.” Most
of us, regardless of our size, have been challenged at times
by clients. This Tip addresses the tricky issue of whether
and how to talk with clients about our bodies.
If you are slim, you may have heard:
“You never had a weight problem so you don’t understand.”
“Oh, you don’t have to worry about weight.”
“You don’t have to watch what you
“How do you stay so thin? Tell me how you eat.”
If you are larger than the current
cultural ideal, you may get this:
“What makes you think you can help me? Look at you."
“Oh, I didn’t realize you would look like this."
“I’m so glad you can understand me.”
As in Adina’s case, there may be times the client does not
talk with you about your body but has responses
or beliefs that get in the way of treatment.
Here are some
common responses I hear dietitians offer when they are
“I certainly do understand, I am a Registered Dietitian. I have eight years’ experience in the weight management field and have worked with hundreds of people in just your situation.” Notice how defensive this sounds.
If you feel discounted, you might begin like this: “I do have to worry about my weight! I used to weigh 12 pounds more and work hard to stay at this weight.” Unfortunately this encourages the client to compare your weight loss to hers and the session can quickly get lost in argument.
Each of these responses directs the
session into very
tricky territory. They
are responses that address the client’s question or
concern as if it is about your body and not the client’s.
I offer a basic principle to keep in
mind in these situations. When someone asks a personal
question or refers to your body, the question or comment is not
about your body,
it’s about something very important to the client. Clients
don’t shift to talking about others’ bodies unless they
are experiencing strong feelings or hold strong beliefs
about their own bodies. When you direct your response to the
surface statement or question, you are missing an
opportunity to help your client.
You also run the risk of getting into conversational
quicksand. See Tip #18, Personal Questions (available in the
Workbook, Vol 1.), for detailed steps to follow in
responding when you are put in these awkward positions.
Some case examples:
don’t have a weight problem so you don’t understand.”
(This is said in a group introduction to a weight management
program.) You could correct the person about having had a
weight problem or insist that you understand. This does not
address the person’s concern and takes the focus off the
person and onto you. Here is one client-centered response:
“Oh, it sounds like it’s really important if you join
this program that you were being understood.
You would want me and the other people in the group
to know how hard this is.”
Notice there is no need for you to talk about or get
defensive about your body.
You focus on what matters to the client.
If you guessed wrong about the client’s concern,
the client will correct you and you will have more
information and something to address.
don’t have to watch what you eat.” You may be tempted to
launch into the ways in which you do take care with your
food choices because of concern for long-term or current
health issues. Your eating habits and food choices are not
what matters here. The client is talking about her feeling
of having to watch what she eats.
“Oh, so you generally assume that if a person is
thin that means they don’t ever concern themselves with
food choices?” This keeps the discussion on the client’s
beliefs and you are guiding the client to explore her
beliefs and maybe eventually whether they are working for
her. Or here is
another way to respond: “Oh, you assume I just eat
whatever I want? That’s interesting.
Was there something particular that gave you that
impression?” (clarifying question) “Yes, look at you,
you are a perfect weight.”
“Oh, so you figure it doesn’t matter at all what
someone who looks like me eats?
Of course, food choices affect more than weight, they
affect energy level, risk of certain diseases. On what basis
would you most like to make food choices?”
Here you are using the client’s statement to
explore how limiting beliefs affect food choices rather than
having an argument about how you choose food.
you think you can help me?” (This is said with a
judgmental look at your large body.) Notice the key words:
“Help me.” Reflect this back with the emphasis on the
key words rather than on you. For example, “You are
wondering whether you will get the help you need here.”
Maybe follow up with open-ended questions such as,
“What do you know about how you most easily make important
lifestyle changes? What kind of help will you need from
Back to Adina’s question about
“breaking the ice” or preemptively bringing up your size
to address what you believe will be your clients’
reactions. Ask yourself, “What
is my intention in doing this?” Is it to defend
against the negative and dismissive thoughts you imagine the
client has? Is it to prove that you can understand? Is it to
share your success story with weight (or an eating disorder)
in order to inspire the client? The
most client-centered intention for opening the topic of your
size is to allow the client permission to voice concerns and
beliefs that may obstruct your work together. Ideally, time
your offer to moments you suspect the client may want to
bring it up. Since you may be off base, it’s best to keep
your opening as brief as possible.
If the client does not want to pick up on it, you
will not have wasted much time or diverted from what matters
to the client.
Some examples of a client-centered
way to open the topic:
you have any concerns about working with me?”
of my clients wonder if I can help them once they see
look like you might not trust me to be able to help
people want to know something about their dietitian’s
own experience with weight (or eating disorders or
clients feel I am not the best fit of a dietitian for
them. I’m fine with that and don’t take it
are other dietitians in town I refer to. If you are
beginning to think we might not be a good fit, let me
As long as you keep
the conversation on the client’s thoughts, beliefs and
needs, you are conducting the session in the interest of
the client. It is neither always right nor always wrong to
talk about your body with a client.
What matters is that your attention stays solidly
focused on the client and that everything you say is in the
service of the client.
Finally, this Tip might
not apply to you. If you do not have any drive to talk
about your size or eating habits with clients and they never
challenge you, there is no need to open the topic.
to list of Tips
Tip # 72
Life is not holding a good hand;
Life is playing a poor hand well.
The question is not what a man can scorn,
or disparage, or
find fault with,
but what he can love, and value, and appreciate.
Summarizing is a powerful form of mirroring that furthers
the change process. It includes affirming (Tip #
client’s strengths and directing attention in the session
to the client’s reasons to change. You hear the client’s
change talk (Tip #
69) and reflect it back. You
can’t assume that the client has put together his change
talk into an action plan for himself.
You guide him to do this when you summarize what you
There is a metaphor used by Motivational Interviewing
trainers. Your client’s words
are like a meadow. Much of what grows in this meadow is
weeds and grass. However, scattered in there are lovely
wildflowers. These flowers are the client’s change
thoughts. As you wander with the client during your session
through the meadow of his thoughts, beliefs and actions you
are collecting the ones that point toward positive change.
When you summarize the change talk you are presenting to the
client a bouquet that you collected as you walked with him
through the meadow.
Here is an example of some change talk imbedded in a client’s words. Notice that overall the
talk sounds negative because the flowers are overpowered by
I can’t lose
weight. It’s just too hard. I’ve tried before, and it
just comes back on. I know I should for my diabetes, but I really love food and it seems
like when I diet I’m always hungry. (Need)
I go out with
my friends on Fridays, and we try out new restaurants.
Boy, on those nights we have fun. No way am I going
to diet at those meals. Oh, a few months ago I
did stop having those sweet drinks before dinner that
they all like, because I realized I really don’t like them
anyway. But no way will I stop going out with them and
having fun. (Taking
I’m going on
a European tour next summer and I’m sort of dreading it,
because I get so tired when we walk a lot. I wish I could
walk longer. I
want to see all the sights. (Reason)
It’s such a
drag to count everything I eat. I can’t remember to do it
all the time. I
mean, I guess it’s easy enough during the week
when I have a routine, but the weekends are so chaotic.
to be kidding. I’m not going to cart that food record book
around all the time. I’ll
start counting the carbs at lunch during the week, but
don’t make me do it when I go out with my friends.
gives me such a hard time when my blood work is high, but I
just can’t seem to get it down. She is really nice, by the
way. I like this new one.
I do want to
make her happy, but it’s just so hard to remember to
watch my portions. (Desire)
A summary of this discussion might
sound like this:
I hear that
you are frustrated that you haven’t lost much weight yet.
You know it would improve your diabetes and you would really
like to make this nice new doctor happy with normal blood
sugars. You have
another reason too. On this upcoming trip you want to be
more mobile and get the most out of it. You’ve made some
important changes already such as leaving off the sweet
drinks on Friday nights. You’ve put some thought into this
idea of keeping track of your carbs and have decided to do
that this week at lunch on work days.
Did I get it all?
Notice that a
little bit of sustain talk is included in the summary to
support empathy. Most
of the summary is affirmation and mirroring change talk.
takes practice to attend to change talk and then
summarize it back to the client. Of course, your first
efforts will be awkward. One type of practice is to collect
the change talk in your notes after the session has ended.
You could then craft your summary. You
could begin the next session with that summary. Even if you
do not have a chance to share your summary with the client
the first few times, you will be gaining valuable practice.
to list of Tips
Recording Sessions for Self-Assessment
a nutritionist for 21 years, I fell into the trap of
believing that confidence equates with excellent skills.
Recording my clients enabled me to clearly see the areas I
needed to work on. Noticing and intention translated
to immediate benefits — for myself and my clients!
Bush, MS, CNS
As human beings, our greatness lies not so much
in our being able to remake our world
as in being able to remake ourselves.
What are the most
effective ways to continue to advance your skills as a
counselor? I have pursued the answers to this question for
many years. Here
I will share a process that has proven to be effective
across all fields and endeavors. Any nutrition counselor can
apply these steps. It is useful no matter what your
skill level, from just out of school to decades of
First, some background. Swedish
psychologist K. Anders Ericsson has for decades studied the
best athletes, authors, chess players, musicians, teachers,
pilots, physicians, etc. He
has simply observed what the best in their fields do that
makes them a cut above everyone else. He
has discovered that their greatness
does not rely solely on natural talent. For example, Michael Jordan,
probably the best basketball player ever, was cut from his
high school varsity basketball team.
All professional musicians have talent; that is not
what makes the truly great ones stand out.
This expertise is also not related to
years of experience. Research shows that in endeavors like
ours, where there are no concrete measures of success (such
as points scored or time in a race), our confidence and our
perception of competence increase as we gain experience. Unfortunately,
studies show that this confidence
does not equate with actual improvement in success rates.
So what do very successful people do?
Ericsson found a consistent pattern. All these people
repetitively do two things. They attend
carefully to whatever feedback they can get.
And they all deliberately
practice specific skills, particularly skills that are
just beyond their current level (i.e., they push their
These same patterns emerge in research
on psychotherapists who are consistently more successful
than their peers. They
push themselves to develop new skills by finding things to
deliberately practice in sessions.
They request and openly receive real feedback from
their clients and colleagues.
These therapists maintain a belief that they don’t
have it all together yet and can keep expanding what they
can do. Feedback and
deliberate practice then are the keys.
There are many ways to get feedback in
nutrition counseling sessions.
Of course, you can ask your client directly with such
questions as “How are we doing?” “What else do you
need from me?” “What are we doing here that is most
useful to you?”
Here I am inviting you to engage in one
particular version of obtaining feedback and then
deliberately practice something that pushes your envelope.
The feedback is generated by you as you listen to one of your recorded
process of self-evaluation has been used for years in the
best counseling training programs.
Sessions can be either videotaped or
audiotaped. I have found that audio recording is simpler and
less intrusive for the client and quite adequate. The
technology is an inexpensive, small digital recorder placed
near you during the session.
Many of the new ones are smaller than a cell phone
and cost less than $50.
Of course, you need to ask the
client’s permission. The colleagues I have worked with on
this process all agree that the hardest part is getting over
your initial resistance to asking a client for permission to
record a session. But
we found that almost all clients readily agree.
It may help to rehearse your request.
For example, “I have a request that is completely
optional for you. I
will be fine if you say no. I am recording some of my
sessions to learn how to be a better counselor. I will be
the only one listening to the recordings. How do you feel
about my recording our next session?
You could take a few days to think about it.”
Record sessions that are typical for
you. These recordings are your baseline. Just two or three
sessions should be plenty.
Listening is the next step. First, just
listen to observe anything that pops out. You could listen
for things like your tone of voice and what percentage of
the time you talked. You
could practice putting yourself in the client’s shoes.
If you were this client, would you want to make the
suggested changes and come back for a follow-up appointment?
Then pick a 10–20-minute section to
analyze more carefully. Most counselors find it useful to
transcribe bits of it. There is no need to transcribe every
what to look for and transcribe the key words.
for all your questions. Jot down the key words of the
questions and then characterize the questions as open or
the wording you tend to use in questions. How many begin
with “Why” vs. “How” and “What”? (Tip #17, available in the Practice
Workbook, Vol 1)
for your reflections: Do they seem to accurately reflect
back to the client what was said or felt or meant? (Tip
#6, available in the Practice
Workbook, Vol 1 and Motivational Interviewing in Health Care,
Chapter 5, by Rollnick, Miller and Butler.)
at your statements/advice: Are they mostly imperatives
or neutral statements of fact? (Tips #39, available in Practice
Workbook, Vol. 2 and Tip
# 59.) Do you
ask permission before providing advice? (Tips #4, available in the Practice
Workbook, Vol 1 and 37,available in Practice
Workbook, Vol. 2)
This analysis can take as long as an
hour even for a 10-minute section of recording. Allot the
time so you won’t be interrupted. Ideally, find a
colleague or several with whom you can share what you are
share the tape, just discuss what patterns you notice and
what you are going to work on next.
You can also learn from listening
carefully to what the client says. Jot down and tally all
the change talk you hear. (Tip
#69) How much of the change
talk did you reflect back?
Did you summarize it?
Just getting this far in the feedback
process may be enough to nudge you to shift some of your
habits. If you are ready to challenge yourself more, pick
something to work deliberately on.
Remember that deliberate practice of specific skills is what brings excellence.
Choose one thing to practice that you would like to
incorporate or do more of. For example, if you notice hardly
any reflections, this could be the next skill you work on.
You may decide to ask permission more often or to
work on the wording of your advice.
My sincere gratitude to
all the dietitians who experimented with this process and
provided valuable feedback, especially Nan Allison, MS, RD,
LDN; Corinne Bush, MS, CNS; Laura Biron, MBA, RD, CD;
Georgia Clark-Albert, MS, RD, LD; and Julie Taborsky, MS,
to list of Tips
To Weigh Or Not to Weigh?
No matter how long your journey appears to be,
there is never more than this:
one step, one breath, one moment — now.
Fear is like a hologram.
It seems real, filled with substance.
Then when you go beyond it,
you realize it’s only an illusion.
I weigh my clients?” I
am asked this in almost every one of my workshops.
The question comes up most compellingly with clients
with eating disorders. It
is wise to consider the pros and cons of weighing with all clients. Seeing the
number on the scale can trigger anxiety for clients, and, as
a result, the counselor may get anxious, too.
How best to approach this process to maximize
treatment and help our clients move toward a normal
relationship with food and their bodies? There is no right
or wrong way that fits all cases.
Some of the advantages of weighing clients in your
and the client have concrete
feedback on the effect of dietary changes.
can tie the process of seeing the weight into the counseling process. This may include working with the
client’s distorted thoughts.
client avoids the
discomfort of being weighed in a medical setting
that may not be private. If the physician needs to know
the weight, you can provide it.
client can choose whether to know the number on a given
allows flexibility if a client is moving away from reliance on the
number as a measure of self-worth.
client who is struggling to let go of purging may need
to know that the weight is stable when experimenting
with keeping food in. If such a client is willing to
trust you to blind weigh and to tell her if the weight
goes outside a certain range, this can help smooth out the drastic extremes in behavior characteristic of
those with bulimia.
The downside of weighing as part of
in your session maintains the focus of your work on the outcome
(weight loss or gain) rather than the process
of behavior change and life enhancement. Change is more
likely to be permanent when the process is attended to
and affirmed. Focus on weight is less effective because
the person does not have direct control of that outcome
the way she has control over her behavior choices.
clients will look at the number and immediately
translate it into a
measure of self-worth.
The resultant shame or elation may distract the
client from the work of making real change. Refusing to
participate in the thought process of “weight =
value” by not weighing in your session can send a
spent in a session talking about weighing and who and
how to do it is time well-spent. Developing ground rules
provides safety and can lessen a client’s anxiety.
Explore what weight means to your
we did weight here, what would it be like, what are your
worries? What thoughts and feelings would you have just
before coming into my office?”
you weigh yourself (or you are weighed at the
doctor’s), what happens in your head after you see the
going two days (or a week or a month) without knowing
your weight? How would you cope with the anxiety? What
other ways do you have to decide what kind of day you
are going to have?”
you see the number has gone up (or down), what is your
Many clients with eating disorders have
underlying anxiety disorders, either Generalized Anxiety Disorder or
Anxiety can be triggered by seeing or by not seeing
the number. Such
a client may be using the number on the scale in an attempt
to manage anxiety. Unfortunately this is a trap that
backfires in the long run. The most effective approach to
the irrational behaviors that have developed to cope with
anxiety is to challenge the fear head-on in small steps.
The fear diminishes over time as the client sees that
nothing terrible happens. A certain degree of anxiety is
unavoidable as the client learns new eating behaviors, risks
new foods and practices new ways to assess self-worth.
Always making the decision to weigh or not based on minimizing anxiety may slow a client’s pace
of recovery from eating problems. For example, as part of
the process of coping with anxiety, some clients find that
it is useful to see the weight as it changes so they can
practice coping with the fears that come up each week rather
than the more vague fear of what is happening that persists
throughout the change process. If you suspect you may be
colluding with the eating disorder or anxiety disorder, ask
the client’s therapist for input.
Your part can be to offer to help the
client shift over
time to less attachment to the number. You can bring up
the idea of blind weight and/or tapering frequency. Some of
these clients have an extreme attachment to a certain
number. They may
play games with you about whether to see the number. These
patterns are important to notice and report to the
client’s therapist so they can be addressed in the context
management clients weigh themselves during a diet more
often than is rational (i.e., daily) and then when not on a
diet, don’t weigh at all. You can offer to help this type
of client find a happy medium of using the scale as a
reality check by routinely weighing once or twice a month.
This may be a challenge for people who have yo-yoed many
times. Developing new habits of weighing will be just one
part of shifting to a more balanced lifestyle. Some clients
who are unable to disentangle the scale from their sense of
worth may do better by using a particular piece of clothing
as a reality check.
job is it to weigh?
For some clients, medical risk necessitates tracking
weight closely. Weighing at a doctor’s office may be more
accurate if a client is “cheating” by putting heavy
items in pockets or fluid loading. Regular, frequent doctor
visits also convey that this is indeed a medical issue.
Vital signs can be monitored, too. If the medical risk is
insignificant, a primary care provider may prefer to have
you weigh the client and report the weight only if the risk
worsens. Many therapists prefer to not weigh clients to
maintain focus on the underlying issues. If the client is
being weighed, this is important information to provide the
therapist in your reports.
For some clients, weighing
themselves helps them feel in control.
They can report changes to you. Of
course, a client who exhibits anorexic behaviors, including
over-exercise, needs to be weighed by someone.
Ideas for the weighing process:
can call the weight a “reality check.”
portion of the data collected along with energy
level, degree of appetite/hunger, mood, sports
performance, self-esteem, etc.
could blind weigh.
Ask the client to step on backward. Jot down the number
and maybe not discuss it then at all. When you agree on
blind weights, make sure to clarify what, if anything,
you will say about the number.
For example: “It’s in the range we agreed
on.” Or, “It’s still going up slowly like we
discuss and then summarize
the procedure before the first weight.
For example, with someone in recovery from
anorexia: “So we’ve agreed that seeing the number
keeps you focused on weight and not on feeding yourself
better, and we’ve also agreed that someone seeing the
weight every two weeks will be a good reality check that
we can use in the future if we need it.
So step on backwards and I’ll just record the
number for us to refer to later. I promise that I will
tell you if it is going up faster than the 1 to 2 pounds
a week we agreed on and I will tell you if it is not
going up at all or going down.” Or with a weight-loss
client: “You want to know if you are making progress,
so we will weigh every week and we will make sure to
discuss your reaction to the number.
After three weeks, we will review how this
weighing process is going and maybe adjust.”
clients who will see the weight, weigh early in the session so there will be ample time to discuss it.
Start with “What are your thoughts about what
the scale says?”
can bring up the idea
of changing how you do the weighing by reflecting:
“I notice that seeing the weight gets you off track
from your goal of eating in a more stable manner. Would
you be willing to look at other ways to handle this?"
As you can see, there are lots of
factors to consider when answering the question “Should I
weigh my client?” Answering these questions first will
likely allow an answer to emerge for each situation:
What matters most here? What will the two of you use
the number for? Where does the client want to be eventually?
to list of Tips
Some people regard discipline as a chore.
For me, it is a kind of order
that sets me free to fly.
All changes, even the most longed for,
have their melancholy;
for what we leave behind is a part of ourselves;
we must die to one life
before we can enter into another!
There are several types of endings in
nutrition counseling. They
include ending meals, ending sessions, and ending treatment.
endings are related and support one another. This Tip will
focus on ending treatment. See Tip #21 for issues with
ending sessions. (Available in the Practice
Workbook, Vol 1) These suggestions apply
primarily in settings where treatment is extended and you
form a relationship with your clients. This includes work
with eating disorders, disordered eating, diabetes, and
comprehensive weight management.
Reasons you may need to end
parental leave, illness, moving or leaving a position.
are not getting enough support from other professionals
or the client’s family. Examples: Parents expect you
to treat their 8-year-old child for obesity without
attending the sessions themselves. You are working with
a young woman with anorexia, and her therapist will not
return your calls.
client is not following your treatment recommendations
for level of care or adjunct treatment. Examples: You
begin to see a man with type 2 diabetes who says he
wants to work only with you and will not see a doctor
for medication management. A woman with bulimia
initially agreed to see a therapist and has provided one
excuse after another as to why she has not begun yet.
assessing the client, you realize you are not qualified
to treat this person.
For example, you discover the client has an
active eating disorder and you do not work with eating
disorders or choose not to. Of course, it is best to
screen out these situations even before the first visit,
but this is not always possible.
client’s goals have been met, and there is no need to
continue nutrition counseling.
The process of ending treatment will
depend on the reasons.
If the reason is entirely yours (i.e., you are moving or
taking a leave):
the client as soon as is practical. Generally the longer
you have been working with a client, the longer the
notice needs to be.
other professionals are working with this client, too,
notify them just before you tell the client.
the client a chance to respond to the news. “This must
be a surprise to you…”
clients who seem upset or sad that they will lose you,
acknowledge the loss. “We have worked together for
quite a while. I can tell this is hard (or sad or scary)
for you.” There
is no need for you to go beyond listening and mirroring
the feelings you hear. If the reaction seems extreme,
inform the client’s therapist and/or seek supervision.
referrals to colleagues who can continue treatment (if
warranted). Offer to provide a report or phone call to
the new nutritionist if the client wishes and with the
If a colleague within the same hospital/agency
will pick up the treatment, inform the client that you
will be filling in your colleague on what you have been
clients will ask questions about your move (or pregnancy
or job change). What matters in this relationship is how
the client will adjust, and finding the client the best
match. Your reasons for ending are not
the issue. Clients, especially those with loose
boundaries, may try to draw you into such a discussion.
When you need to insist on ending
for professional reasons:
by stating what you know to be true. “In order for
your son to learn new eating habits and slim down, he
needs your support.
This is why I always work with families
together.” “We have been meeting for three weeks,
and it is still too hard for you to follow the food plan
and keep from losing weight. This means a higher level
of care is needed in order to make progress in
your conditions clear by showing respect and keeping the
door open (If you are willing to continue.) “I
would be glad to work with you on a healthy food plan if
you are also following your doctor’s
recommendations.” “We will not schedule another
appointment until you have seen a therapist at least
When you must refer to a colleague:
your limits. “I don’t have expertise in…” “My
schedule here only allows monthly visits.”
your commitment to the best treatment for this person.
“I want you to have the very best care.” “I
believe that weekly visits are best for you at this
be persuaded against your better judgment. It is not
uncommon for clients to underestimate their condition or
to prefer you for their own reasons such as convenience
or liking your office. If your professional opinion is
that they would be better treated by others, stick with
the client contact information for at least one
Ending successful treatment:
When you and the client agree that
treatment goals have been reached or a break in treatment is
reasonable, offer to have one more session to carefully end
your work together. There are several useful things to do in
a “termination session,” as therapists call it.
for the client’s version of your journey together.
“Tell me how you look at these months we have been
meeting.” This allows the client to further integrate
the change process.
the client’s response does not include certain areas,
you could follow up with open-ended questions: “What
brought you in?” “What do you know now that you
didn’t then?” “What are you taking with you?”
the client leaves out things that you believe are
significant, offer to add them. “Sarah, I wonder about
that time when you came in telling me you had finally
left some food on your plate and it wasn’t so bad. How
does that fit in with your experience?”
the relationship has been a long one and you feel
inclined, you could briefly
add something from your side. “Sarah, I have been
honored to accompany you on this journey making these
Taking time and respect with endings reinforces the value of
to list of Tips
That is what learning is.
You suddenly understand something
you’d understood all your life,
but in a new way.
You can’t fake listening.
Scaling questions are
designed to encourage a client to fully explore a proposed behavior change. When
you ask these questions, the client is obliged to thoroughly
search all the factors involved and to truly think about
changing. You elicit the client’s motivations to change,
her strengths and obstacles.
In a Motivational Interviewing style of counseling, the two
areas explored with scaling questions are Importance (Tip
#20, Unpacking Meaning, available in the Practice
Workbook, Vol 1) and Confidence (Tip #42, Boosting
Confidence, in Practice
Workbook, Vol. 2). Importance is generally explored first and
then the confidence to make a specific change or changes is
examined as a way to move
the change process along. Let’s look in more detail at
how to use this process most effectively.
Language for introducing scaling:
a scale of 1 to 10, where 1 is not important at all and
10 is extremely important, how important is it to you to
get your blood sugar into the normal range (or become
more physically fit, or eat more fruits and vegetables,
said on the phone that you want to work on lowering your
cholesterol. How important is it to you on a scale of 1
a scale of 1 to 10, how confident are you that you can
cook dinner at home at least two nights a week?
confident are you that you can keep this food record for
the next two weeks, on a scale of 1 to 10, where 1 is
not confident at all and 10 is very confident?
down and accept everything the client says. Don’t just
acknowledge the number and move on. Reflect back what you
hear, especially any change talk (Tip
#69). Ask follow-up questions to clarify the elements
involved. In this process, the client does most of the
talking. The client is doing the work of thinking about and
strategizing for change. You are simply providing the
Language for furthering the
say it is a 5 in importance for you to get off this
medication. What makes it a 5 instead of a 1?
seems quite important to you. What would have to be
different to make it even more important?
sound moderately confident that you can begin an
exercise routine. What contributes to the confidence you
gave your confidence a 6. What gets in the way of your
confidence being an 8?
the client for a specific number is useful because you
can then ask the “What makes it so high?” and the “How
could it be higher?” questions easily. Some clients seem
to prefer using words, such as “really important,”
“not a big deal,” “well, sort of important.”
You can still ask the follow-up questions. At some
point in the process, stop using the numbers and reflect
back the specifics (i.e., what motivates the client, the
obstacles and strengths). As
you wind up the process, don’t forget to summarize (Tip
You may find yourself asking “Why?” often in this
example, “Why is it a 7 instead of a 2?” “Why is it a
5 instead of an 8?” You may find that using “What?”
and “How?” wording in your follow-up questions elicits
richer content. For example, “What makes it at 7 instead
of a 2?” and “How would the number get higher?”
Some clinicians jot down in the chart
the numbers elicited as a measure of progress. This may be
useful for those who must document sessions. Remember that
this is not the purpose of scaling and can distract the
counselor from focusing on the client’s change process.
The numbers are not as meaningful as the thought process
that they initiate in the client.
to list of Tips
Professional Working Relationships
The most important single ingredient
in the formula of success is knowing
how to get along
If everybody is thinking alike,
then somebody isn’t thinking.
Clear lines of
communication form the foundation of healthy relationships. This is particularly true in
When you coordinate care with other professionals,
the quality of your work depends on a conscious effort to
stay in touch with team members.
Your communication may take various
forms (of course, take care to keep all client
in patient charts
calls or voice mail messages
messages or reports
conversations either in formal case conferences or
Your communication may:
your treatment plan
a request for information
care for the referring source
care when the case is complex
The guiding principle in every
communication is the best
care for the client. What do the other team members need
to hear from you and what do you need them to know? Request
what you need so you can best do your part. Do you need
updated medical information or to have the physician weigh
the client? In some cases, hearing about psychological
themes or family background from a therapist may help you
understand the client better. You may find it useful to get
feedback from others on how the client is responding to your
visits. When working with a new professional, ask what
he/she will need from you and what form of communication is
Your communications may have the side benefit of building
your practice. Referral sources who hear from you
consistently with professional, useful input will most
likely refer more clients to you. You can even nurture
and improve the referral process. Thank the referral
source for sending the client and, if appropriate, mention
how important it is for the client to be well-prepared for
An example: I fine-tuned my relationship with a local
primary care doctor over the course of six months. When I
got the kinds of cases I like and do well with, I thanked
her for referring the client and told her specifically what
made the case such an appropriate referral.
When I got inappropriate referrals, I referred the
client to a colleague and then sent a brief e-mail to the
doctor telling her that I appreciated the referral and that
I had referred the client to my colleague because she works
best with those types of clients. I included my
colleague’s contact information.
After a few of these, I got fewer inappropriate
referrals and more of the ones I like. Once, I heard from a
client that this doctor had reassured him that I would not
force him to give up his favorite foods, and that if she had
not promised this, he would not have made the appointment. I
left a voice mail for the doctor thanking her and informing
her how powerful her words had been. Positive reinforcement
Certain cases need closer communication than others. The
most complex outpatient cases
often involve eating disorders. It is not unusual to
have some form of communication between the dietitian and
the therapist (and maybe the physician) between each visit.
This is vital if the eating disorder causes the client to
lie, or the client has Borderline Personality Disorder (Tip
In inpatient settings, documentation using the Nutrition
Care Process and Language is the clearest way to communicate
with other professionals who treat your patients.
However, don’t neglect the value of face-to-face
contact. If your setting is an agency, hospital outpatient
department or college, you may have the advantage of a
regular case conference.
Use these to be an active member of the team. If
there are no case conferences, consider asking for them.
Those new to private practice may struggle to find other
professionals for working relationships.
You will need to refer to psychotherapists, personal
trainers, physical therapists, and personal chefs or
physicians. Build your network over time:
local listings and visit or ask to have coffee with some
of them. You can ask
for referrals from them while finding out what kinds of
referrals they want from you. This personal contact is
an essential part of developing and nurturing these
to your clients. If they mention a professional they
like and respect, get the name and contact information.
other professionals about what you can do. Don’t
assume they have had good working relationships with
nutrition professionals in the past. Ask what their
experience has been and state what you can do and how
you would like to coordinate care with them.
When problems arise:
phone calls are not returned.
member of the team gives nutrition advice (maybe
contradicting your advice).
on the team does not get what you do or doesn’t
acknowledge you as part of the team.
A suggested process to deal with these issues:
if the situation is harming the client or is just
annoying to you.
for yourself (maybe with the help of supervision) what
the issues are and what you want/need. Couch
it in terms of providing the best care for the client.
your concern to the person/people. Ask for a response.
you are unable to make contact or resolve the issues and
believe it is jeopardizing the client’s care, end
treatment with care and respect (Tip
to list of Tips
When we were children,
we used to think that when we were grown-up
we would no longer be vulnerable.
But to grow up is to accept vulnerability...
To be alive is to be vulnerable.
The human spirit is never finished when it is defeated…
it is finished when it surrenders.
Some of our clients are survivors of
traumatic events. Trauma occurs when a person experiences or
witnesses first hand an event or series of events that
include actual or threatened death or serious injury. Humans
respond to trauma in many ways.
Acute responses to trauma:
• Memory difficulty
• Feeling emotionally numb
• Trouble concentrating and problem-solving
• Vivid and sometimes intrusive memories of the event.
• Increased anxiety and hypervigilance
• Difficulty controlling feelings
• Anger and/or aggressive feelings and behavior
• Difficulty sleeping
Additional symptoms and behaviors that may appear later:
• Despair and hopelessness
• Shame and guilt
• Difficulty trusting and relating to others
• Drug and/or alcohol abuse
When symptoms persist for more than three months the
person may be suffering from Post-Traumatic Stress Disorder
(PTSD). Much progress has been made in the treatment of
acute trauma reactions and PTSD. As a nutrition
professional, you are not treating the person for trauma. It
improves your work when you understand what you are seeing
and if appropriate refer to someone who is experienced
helping people work through trauma.
If the trauma is recent (i.e. you are asked to see a
patient with diabetes who is recovering from a car accident
the day before) the person is still acutely traumatized and
apt to have a poor memory, trouble concentrating and making
decisions. Keep your expectations low. The patient may want
to tell you the story of the trauma. If you have time and
are willing, just listen. People who have recently
experienced trauma need to tell the story over and over in
order to work through it. If necessary, ask if you can
return later to accomplish your clinical goals.
If the trauma was more than three months ago and the
client wants to tell you the story in detail this is a clue
that the experience is not being worked through properly.
Redirect the conversation to health and nutrition. If the
client persists and/or you notice any of the long-term
symptoms above, consider a referral for mental health
If you work in a psychiatric facility or with clients
with eating disorders you will encounter the effects
of trauma in many of your clients. Find out from other team
members which clients these are and follow their advice as
to how to work with the on-going behaviors. Effective
nutrition counseling in these settings requires extra effort
on the counselor’s part to cope with the client behaviors
that come from trauma. It is well accepted that work with
these clients is most effective when all team members
communicate carefully and often. (Tip
When a client tells you of a horrifying experience it is
normal to experience a milder version of the symptoms above.
In addition you may feel a sense of incompetence or
hopelessness. This is called secondary trauma or vicarious
trauma. (Tip # 49, available in Practice
Workbook, Vol. 2, has more on this parallel process) The more
empathetic a person you are the more you will be affected.
Empathy is an important quality of effective counseling.
Limiting your empathetic response with these clients will
protect your from burnout. (See Tip # 22, available in the Practice
Workbook, Vol 1, for ideas on minimizing burnout.) You
are also more at risk for secondary trauma if you easily
identify with the client. For example, if the client is your
age and has a similar background you may be affected more
deeply. If you notice any of those symptoms in yourself find
someone to talk to and make a plan to care for yourself.
(See Tips # 8, 16 and 19, all available in the Practice
Workbook, Vol 1, for ideas on self-care.) Clinicians who
have adequate balance in their lives are less apt to be
seriously affected by secondary trauma. It is common to feel
like isolating from others when you have been traumatized
(whether directly or indirectly). Resist this impulse by
reaching out to colleagues and loved ones for support. If
working with such clients takes too much of a toll on you
and you can not maintain balance, consider shifting to
part-time in this setting or switching to another area of
to list of Tips