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Counseling Tips for Nutrition Therapists Series
2008 Archives

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

1. This must appear at the end of each Tip:
                  © 2008 Molly Kellogg, RD, LCSW
                  www.mollykellogg.com
2. Don't edit the copy at all without checking with me.

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The first 25 Tips and much more are in my new Practice Workbook

Counseling Tips for Nutrition Therapists: 
Practice Workbook, Vol. 1

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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 Disorder (4/1/08)
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 Self-Assessment (7/1/08)

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 feedback:  

• Remind 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.

• When offering the feedback in individual sessions, use the Elicit/Provide/Elicit format described in Tip #59. Ask 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 client’s perspective.  You are saying that the client’s response to your feedback is important in the process.

• Whenever possible, encourage the client to take a look at the records before you provide feedback.  “What do you make of this?” “What do you want to learn from this?” This sidesteps the trap of your judgment while helping the client get in the habit of analyzing and learning from the experience. 

• If 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 model a 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. 

• Spotlight the process.  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 judgment.

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 feedback:  

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 understand.  Reflect 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.

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
 in your 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 yourself.  Holding the hope for the both of you is valuable, especially for clients with eating disorders or frustrating medical conditions.  When 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 you.”

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 Workbook, Vol.1.)  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. 

Expanding the 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 Vol. 2 e-book)

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 in place.

Hopelessness is not the same as helplessness.  We 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 situation.  When 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. (See Tip #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 #55, Ambivalence.)

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 benefits?

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Tip #69 Change Talk

Motivation is a fire from within.
If someone else tries to light that fire under you,
chances are it will burn very briefly.
 Stephen R. Covey

Celebrate what you want to see more of.
Tom Peters

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 change talk.

Desire: Statements about preference for change.

• “I want to…”

• “I would like to…”

• “I wish…”

Ability: Statements about ability.

• “I could…”

• “I can…”

• “I might be able to…”

Reasons: Specific arguments for change.

• “I would probably feel better if…”

• “That would give me more energy to…”

• “This keeps me from…”

Need: 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.

Commitment: Statements about likely change.

• “I will…”

• “I am going to…”

Taking Steps: Statements about action taken.

• “I actually went out and…” 

• “This week I started…”

• “I am now doing…”

You 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 Workbook, Vol.1.)

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.

• Desire: “What do you want, like, wish, hope…”

• Ability: “What is possible? What could you do? What are you able to do?”

• Reasons: “What would be the benefits? What would get better?”

• Need: “How important is this change? How much do you need to do this?”

• Commitment: “What are you going to do? What will you do?”

• Taking 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 Butler , 2008.

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Tip #70  Borderline Personality Disorder

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 medication.  There 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:

• Frantic efforts to avoid real or imagined abandonment
• Unstable and intense interpersonal relationships alternating between extremes of idealization and devaluation
• Significant unstable self-image or sense of self
• Impulsivity that is potentially self-damaging
• Suicidal behavior, gestures or threats of self-mutilating behavior
• Mood instability lasting a few hours
• Chronic feelings of emptiness
• Inappropriate intense anger
• Paranoid 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 other.  For 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 them.

Typical things you might see:

• The client swings between saying you are the very best dietitian ever to being the worst.
• The 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.
• The client will express what seems to be an inappropriately strong fear of being abandoned by you or someone else.
• The client is unusually friendly and seems to want to know all about you.
• The client’s mood or personality seems surprisingly different from one session to another.
• The 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:

Maintain 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 Workbook, Vol.1)

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 said.

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.

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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 want. 
Zig Ziglar

When you blame others,
you give up your power to change.
Douglas Noel Adams

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 eat.”

• “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 challenged: 

• “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 Practice Workbook, Vol 1.), for detailed steps to follow in responding when you are put in these awkward positions.

Some case examples:

“You 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.

“You 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.

“What makes 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 me?”

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:

• “Do you have any concerns about working with me?”
• “Some of my clients wonder if I can help them once they see me.”
• “You look like you might not trust me to be able to help you.”   
• “Some people want to know something about their dietitian’s own experience with weight (or eating disorders or diabetes).” 
• “Sometimes clients feel I am not the best fit of a dietitian for them. I’m fine with that and don’t take it personally.  There are other dietitians in town I refer to. If you are beginning to think we might not be a good fit, let me know.”

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.

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Tip # 72  Summarizing

 Life is not holding a good hand;
Life is playing a poor hand well.
Danish proverb

 The question is not what a man can scorn,
 or disparage, or find fault with,
but what he can love, and value, and appreciate.
John Ruskin

Summarizing is a powerful form of mirroring that furthers the change process. It includes affirming (Tip # 63, available in Vol. 2 e-book) the 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, available in Vol. 2 e-book) 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 hear.

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 weeds.

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 action)

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.  (Ability)

You’ve got 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.  (Commitment)

The doctor 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.  

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.  

It 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.

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Tip #73  Recording Sessions for Self-Assessment

As 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!
Corinne 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.
Gandhi

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 experience.

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 envelope). 

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 sessions.  This 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 word.  Decide what to look for and transcribe the key words.  Some examples:                                      

• Listen for all your questions. Jot down the key words of the questions and then characterize the questions as open or closed.  (Tip #60)
• Analyze 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)
• Search 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.) 
• Look at your statements/advice: Are they mostly imperatives or neutral statements of fact? (Tips #39, available in Vol. 2 e-book and Tip # 59.) Do you ask permission before providing advice? (Tips #4, available in the Practice Workbook, Vol 1 and 37,available in Vol. 2 e-book.)

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 learning.  Don’t 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, RD.

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