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:
2009 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 # 79 Choice
Points in Your Career (1/1/09)
Tip # 80 Pushing Your Skills
Tip # 81 How to bring Up Tough
Tip # 82 Issues of a Home
Tip # 83 When You Make a
Tip # 84 Working with Groups:
An Introduction (6/1/09)
Tip # 85 A Random Collection of
Strategies for Groups (7/1/09)
Tip # 86 Attending to Language
in Groups (8/1/09)
Tip # 87 Problems that Arise
in Groups (9/1/09)
Tip # 88 Our Role in Groups
Tip # 89 Phone Counseling
Tip # 90 Curiosity
Choice Points in Your Career
Follow your instincts.
That's where true wisdom manifests itself.
It is easy to say No, when
there is a greater Yes.
We all encounter important
choices in our careers.
Opportunities come along, and we decide whether
to accept them. We consider volunteering for a
professional group or nonprofit. We feel stuck in a job
and struggle with the choice to switch positions or even
careers. We struggle with the balance of career and
Careers are filled with these choice points. When we fine-tune
the process by which we make these decisions, the
payoffs are clear. We are happier in our work, maybe
more effective and certainly more prosperous. Here is a
strategy for aligning your choices with your priorities
Develop a list of values. Here are some questions
to get you started:
important is maximizing income? Do you have a
bottom-line figure you will work for? Is reliability
of income (i.e., salary vs. entrepreneur) important?
you prefer working with clients/patients one-on-one
or in groups?
you prefer counseling clients in a continuing
relationship or only once?
about the independence of your work, the amount of
supervision you thrive with, the amount of
collaboration with colleagues, etc.?
you want to be pushed to continue to learn and
upgrade your skills?
you want a position that includes complex,
academically challenging cases?
it important to you to work in a well-respected
important is the ethical conduct of co-workers and
variety in your weekly duties a must?
giving back to your profession important to you?
much do you care about the length and type of
you want opportunities for research (your own or as
part of a team)?
you crave a boss or mentor you can learn from, or a
boss who is there and responsive only when you have
you want opportunities to teach (medical students,
nurses, college students, dietetic interns, etc.)?
age group and medical conditions do you prefer to
work with or do you prefer a big range?
you want to get into a new area of practice?
If you take on consulting work, you might
is your bottom-line hourly rate (including travel
time and expenses)?
this contract likely lead to more of the work you
it be necessary for you to let go of some other work
to take this on?
this work further your long-term goals?
Use these questions as a beginning and add more items
that matter to you.
Then rank each as:
A - Absolutely essential, I won’t compromise on
B - Important, but I might compromise to get other
things important to me.
C - Would be great, but it’s icing on the cake.
As an example, part of one person’s list might
look like this:
more than 20 minutes from work to my daughter’s
day-care site – A
in same location that I can look up to and learn
from – B
with pediatric population – A
RD interns – C
that understands needs of my family and will allow
time off if I need it – B
where I need to continue to learn and stay up to
date on research – B
who encourages involvement in professional groups
costs paid for – C
with eating disorders (less than 15%) because I want
to see if I like working with that population - B
Develop and play
with your list using what you know about yourself.
You may have learned from negative experiences
what does not work for you. Your intuition will guide
you toward your truths. Some people describe a sense of
“flow” when doing work that is rewarding. I have
learned to pay attention to when I am having fun. This
is my signal that I am doing what I want to do more of.
These values will likely shift over time, so update your
list at least once a year.
When looking for a new job or encountering an
opportunity, take out your list and see if there is a
match. Avoid these traps when deciding:
get offered a job at a prestigious hospital, which
feels good to your ego, but this is not on
your list of values.
pay you are offered is much more than you had
anticipated and you allow that to override some of
your other values.
position has exactly the population you have always
wanted to work with, but to take it, you will need
to compromise on some of your “A” items.
are asked to take a volunteer position (or speak for
free) and you are so flattered that you forget to
run it through your values list. People who ask you
to do something for free will often try to flatter
you into a yes. You can choose to accept the
compliment but not the work.
can get us in trouble, too. Of course, successful
careers involve lots of give and take. You get help
from colleagues and then return the favor later. When
you consider giving your time or expertise, make
sure it will not disrupt your values.
If you are asked to assist someone to whom
you owe something, pause first and consider what it
will mean to you and your work. A good rule of thumb
is that if you would feel resentful if you did it,
it’s time to say no. You could offer to do
something else or acknowledge that you want to
return the favor, but this one is not going to work
Successful careers are built on high-quality
decisions made at numerous choice points as they come up
over the years. Use this process over and over to tweak
your way to the life and career you want.
to list of Tips
Tip # 80 Pushing Your
I am always doing that which I cannot do,
in order that I may learn how to do it.
As human beings our greatness lies
not so much in our being able to remake our world
as in being able to remake ourselves.
To “push the envelope” means: To attempt to extend the current limits of performance. To innovate, or
go beyond commonly accepted boundaries.
Clasp your hands together with
Now let go and do it again. Notice that you do it
the same way each time.
Notice which index finger is in front. Now slip
your fingers over one so the other index finger is in
front. How does it feel?
Weird? Of course
it feels weird. You are not used to it.
This does not make it wrong.
We all get into accustomed patterns
of behavior. This
is certainly true in counseling and education sessions. These
“ruts” are handy and may help you remember to
include everything important.
To advance to the next level in effectiveness,
you can push
outside your comfort zone to try new language or
feels strange, and at first you may believe it is wrong.
When you are ready to push your envelope, choose
one specific thing to practice for a while.
Here’s a list of ideas for new
skills to push yourself into:
silent after an open-ended question and allowing
a client to think and respond
out loud rather
than just in your head
to ask your
client for direction in a session
the change talk you have heard
back a tendency to self-disclose
permission before providing advice
If you are not sure what to work on
next, audio-record a session and listen to it with an
ear for specific techniques or language. (See Tip
#73 for more on this powerful process.) We tend to
do better when we push ourselves with only one
new thing at a time. As you practice, suspend
judgment about whether you will incorporate this new
behavior in your work. Just do it and attend to how you
feel and what happens next.
Assess how it’s going:
When you stretch yourself and
practice new skills, it will
feel weird. Remember, that is not the way to decide
whether to keep doing it.
So, how to tell if this new way of being with
clients is a good idea?
If it gets easier as you practice it, this shows
that you can
choose to add it to your bag of tricks. If it does
not get any more comfortable after practicing a few
times, there are two possible reasons. Either this
technique is just not your style or you may not be ready
to take it on. If you are willing, give it another whirl
in a few weeks or months.
The other important thing to attend
to is the results
when you practice this new skill. Do your clients
respond differently? Is it effective? Do you feel any
more or less tired, anxious or competent?
To continue advancing your skills,
repeat this process over
and over and over.
There is no such thing as an envelope that cannot
to list of Tips
How to Bring Up Tough Stuff
lives begin to end the day
we are silent about things that matter.
Martin Luther King Jr.
of waiting for the perfect opportunity,
I should work toward a realization that
every opportunity is perfect.
No matter your work setting, there
will be times you need to bring up a tough subject with
not appear to want to hear something you believe
is important for her (or a family member’s)
want to scare
someone into changing. Research shows that
confronting someone with dire consequences is not
likely to motivate change. Sharing important
information in the respectful process described here
will more likely be heard.
you have limited time to convey very important
has been ignoring your subtle direction and you
want to get his attention.
The most effective communication
will be brief,
unambiguous and respectful. Here’s a suggested
up the topic and ask to talk about it for a few
minutes (promise to keep it short and stick to the time
limit unless the client becomes engaged in talking about
change). “I would like to talk with you for a few
minutes about these new lab results. Would that be
what you see/know. For example, lab results, current
behaviors, signs, symptoms, what we know about
consequences of behaviors.
Keep your statements to no more than three items
and keep them as clear and simple as possible.
Here’s one format for a
“This number here (HgbA1C)
shows us if over the last month damage is happening
in small blood vessels in the eyes and kidneys.
“This number is very high and tells us that your
average daily blood sugar is well into the risky
hope/instill confidence: “People who cut back
even a little on certain foods and lose just 10 to
15 pounds see a reduction in this lab value and have
much less chance of developing complications.”
a response to what you said. “What is your
response to this?” “What are your thoughts about
this?” “How do you feel about what I've said?"
the client’s response, finding some things to
affirm. “So you worry about your health and would like
to avoid kidney problems.
You have some questions for me about which foods
really make your blood sugar go up and are not sure yet
if you are willing to cut back on them.”
6. If the client has follow-up
questions or sounds
at all ready to address change, shift into the
Elicit/Provide/Elicit process described in Tip
#59. Then ask for next steps: “What do you think
you will do?” “What would be your first step?” “What,
if anything, do you plan to do?”
Here’s an example from a WIC
permission: “May we talk for a few minutes
about what you are putting in your baby’s bottle
“I can see that you care very much for your baby
and want to be a really good mom for him.”
“Sweet beverages in a bottle at night cause teeth
hope/instill confidence: “Babies easily get
used to plain water in the bottle or a pacifier.”
a response: “What is your response to this
“So you are surprised to hear about the effect the
sugar is having on his teeth because you think of
juice as healthy. You are not confident it would be
easy to change this and still get him to sleep. I
would be glad to talk with you more about this.
I have a few more facts and some ideas about
how other mothers handle bedtime.
Would you like that?”
the client shows no readiness to address change now,
as in this case, ask permission
to bring it up again in the future. “May I
bring this up at your next visit?”
Take care of yourself:
Bringing up a topic that a client
does not want to face will mean breaking rapport.
This is one of the situations where you
step away from following your client’s lead.
You rely on your professional judgment about what
is best for this client.
Preparing for these conversations can help.
Choosing respectful wording takes practice! If you know
you will be confronting a client about something at a
session, plan what few points you will make. Maybe
practice them with a colleague and/or write them down.
Afterward, if it did not feel
it out with someone.
Remind yourself you did the right thing even if
the client did not thank you or respond as you had
assume that the client got nothing. When you present
information and advice in a neutral, respectful manner,
it will likely be remembered and may have an effect
later when readiness shifts.
to list of Tips
Issues of a Home Office
Begin somewhere; you cannot build
a reputation on what you intend to do.
Some people regard discipline as a chore.
For me, it is a kind of order that sets me free to fly.
Feeling safe does not mean we have no fear.
It just means we have some confidence that
we can deal with what scares us.
I am often asked about seeing clients in a home office. The most common questions are:
Is it professional enough?
What about male clients whom you don’t know?
Do I need to have a separate room or separate entrance?
There are clear practical advantages to locating your practice in your home, such as the low cost and no commute. A fundamental question is how to balance your needs with what is best for your clients. A home office is indeed less professional than an office in a medical or office building. This affects you and your client. If you choose a home office, you will not have the physical environment that says, “A competent professional works here.” You can work to structure your home and conduct yourself in such a way as to
maximize a professional look and feel. This will have a positive effect on the counseling relationship.
Structure your environment:
If one room is used for both client visits and your personal
needs, such as your living room, dining room or kitchen, you will run into several possible problems. For example, you will need to keep that room and visible areas of your home neat and neutral. Are you willing to insist your family pick up all their personal items on work days? You may find that your professional decorating style is different from your personal style. Can you decorate the room in a professional manner without detracting from your enjoyment? Furniture designed for relaxing in your den may not be conducive to working with a client on diet changes. One dietitian who uses her dining room to see clients purchased a desk that closes when not in use. When it is closed, the dining room does not look like an office. When she opens it, she feels and looks as if she is at work and has handy the files and food models she needs. She repositions her dining-room chairs at the desk and can focus on her client. She even decorated the room with tasteful photographs of fruits and vegetables that were appropriate for her office as well as her dining room.
The ideal is to have a separate room that is either entered from the outside or from near a door. A nice basement room may have an outside entrance. An appropriate room may be located off the front hall. In my case, the den has a door onto a sunroom that serves as a waiting room. A front hall can be used as a waiting area. Ideally, doors can be closed to shut off the rest of the house. If you have no waiting area, educate clients about waiting outside until the allotted time and allow some time between sessions. Not having a waiting area may also help you keep to time limits.
Some clients will need to use a bathroom. Do you have one close to the office space that can be kept neat and neutral? Paper towels have a more professional feel than the cloth towels in most home powder rooms.
Put a professional-looking sign outside your house or on or near the door. If you are not able to do this, at least put a small plaque with your name and initials next to your doorbell. This will help set the tone for a business rather than a personal relationship.
If you are concerned for your safety:
See only male clients who have been referred by a professional or friend.
Keep a phone or cell phone handy and visible.
Schedule new male clients only when someone else is in the house. One dietitian asked her husband or teenage son to interrupt the session to let her know he had just gotten home, then quickly apologize and go upstairs. This is not ideal for keeping professional boundaries but was necessary for her to feel safe. They did this until she became more comfortable. She does not feel the need anymore.
Maintain professional boundaries:
You can indicate to your clients that this is a professional relationship by taking extra care to maintain all other professional boundaries. With new clients, this is particularly important as the relationship is being established.
Carefully keep to agreed-upon time
limits. (See Tip #21, Time Boundaries, available
in the Practice
Workbook, Vol 1.) A social visit generally has a vague time limit, if at all. Mention the time on the phone when setting up the visit and then keep to it.
It can be more difficult to limit self-disclosure if you are in your home. (See Tip #1,
Self-Disclosure, available in the Practice
Workbook, Vol 1.) Strictly limiting it during the session, especially at first, sets the tone. This can also mean training your family to stay away from the office area of the house. You may feel more comfortable scheduling clients only when family members are out. If you have family pictures around, move them to another room. Visually scan the part of your house that will be visible to clients and clear out what is not neutral.
is always important and may not be assumed by your client if she is coming to your home. (See Tip #45,
Confidentiality, available in Practice
Workbook, Vol. 2) If the client lives nearby, it is more likely to occur to her that you know some of the same people. Get in the habit of mentioning that you will share what is discussed only with specific people, such as her doctor, and only with her permission.
Make sure the counseling relationship does not slip into a
personal one. This is a risk in any nutrition counseling, and conducting it in your home makes this tendency more likely. (See Tip #13, Dual
Relationships, available in the Practice
Workbook, Vol 1.) Deflect questions or comments about yourself and return to the client’s needs. (See Tip #18, Handling Personal
Questions, available in the Practice
Workbook, Vol 1.) For example, my office is in my home, a century-old stone house with interesting character. Often new clients will comment on it. I briefly acknowledge the comment with something like, “Yes, they don’t build houses like they used to.” And then I return the conversation to them: “So did you have any trouble with traffic?” or “You said on the phone that you got my name from your therapist?”
Dress professionally. When I first began my practice, I wore my hospital lab coat when I saw clients at home. It helped me feel in the role and probably had an effect on the clients.
If you don’t feel your home will be adequate for an office and want to keep your overhead low, there are other options. These work best if you are doing it part time.
Sublet an office from a therapist or doctor, chiropractor or massage therapist. They may also be a source of referrals. Notice whether the space conveys what you want it to. For example, when I wanted to add a downtown office one day a week, I was offered the use of an office by a physician friend. I liked the location and it was available on the day I wanted, but the office was very medical and I would be seeing the clients in an examining room. I decided instead to sublet an office in a suite of therapists. This fit my style better.
Look for a suite of offices in your area that rents by the hour.
Rent an office and sublet some days to other nutritionists or therapists.
Ask to use a room in a local gym. Make sure it will be private.
Meet in a coffee shop or other public place. Search for one that has booths and schedule at non-peak times. There are several downsides to this option. Confidentiality is not assured; it may be hard to focus on the work if it is noisy; and it may feel too much like a social visit.
A final note:
I generally ask new clients about their experiences with dietitians. This allows me to learn how to best help them. Many times over the years I have heard something like, “She was OK, but we met in her kitchen and I could hear her teenager’s music upstairs.” “She was good, but it bothered me after a while to be going into this gym to see her. Everyone was so buff.” Or “…but, her office was in a busy pediatrician’s office and it was so noisy.” You never know what each client will find comfortable. You can just do your best to set up a professional, safe environment.
to list of Tips
When You Make a Mistake
Humility is wisdom.
Shame is not.
Give me a fruitful error any time,
full of seeds,
bursting with its own corrections.
perfect. We have all goofed at times and regretted
something that cannot be taken back. Some examples:
gave the wrong information to a client.
double-booked or missed an appointment.
a session, you realize that you missed an important
piece of education.
was a misunderstanding about appointment time,
length, fee, expectations or your policies.
get feedback that you inadvertently hurt a
client’s feelings or offended him.
Professionally handling these
mistakes repairs the counseling relationship and helps maintain your good
reputation. Relationships do recover from rifts and can
even become stronger because of the bump in the road.
Apologies go a long way. Simply and clearly apologize for what you regret doing. A simple
apology is enough unless the client asks for more
information. No need to go on and on or make excuses or
get defensive. “I want to begin our session today with
an apology. I am aware that you ran into one of your
classmates in my waiting room last week. I know you have
not told anyone at school about coming to see me and I
knew you two go to the same school. I should have taken
care to schedule her on a different day. I will make
sure to do that in the future.”
Maybe briefly empathize.
“That must have been upsetting when you left my office
and saw that girl here.”
Often clients will deny that your behavior hurt
out of politeness. When a client says, “That’s
OK,” I have learned to respond, “Well, it wasn’t
OK, and I am sorry.”
Sometimes the client’s “OK” means she
accepts your apology.
It is only your job to apologize and empathize.
It is up to the client to choose whether to take
in your apology and empathy.
With some clients, it may be
necessary to take more care with the repair process.
Clients who have difficulty
trusting, especially those who have experienced
#78), will find it more unsettling.
Taking care to repair the rift will strengthen
the relationship and will help the client learn how to
develop trust. If your client has a therapist, inform
the therapist about the mistake. This can be extremely
useful material for the therapy process.
A vital part of this process is
your ability to forgive yourself for making the mistake.
The sooner you accomplish this, the more professionally
you will be able to focus
on the client and the repair process. If you find
yourself dwelling on the mistake, bring it up with a
colleague or in supervision. Consider laughing at
yourself, “Boy, I am still a work in progress aren’t
I?” Some find it useful to think of quotes such as the
ones at the beginning of this Tip. Here are some more.
is not the misguided act of condoning irresponsible,
hurtful behavior. Nor is it a superficial turning
of the other cheek that leaves us feeling victimized and
martyred. Rather it is the finishing of old
business that allows us to experience the present, free
of contamination from the past.
man who makes no mistakes does not usually make
excellence motivates you; striving for perfection is
the Japanese mend broken objects, they aggrandize the
damage by filling the cracks with gold, because they
believe that when something’s suffered damage and has
a history, it becomes more beautiful.
may in fact disappoint ourselves, may not meet our own
expectations, but we do not cease to be a friend to
to list of Tips
Working With Groups: An Introduction
were not best that we should all think alike;
it is difference of opinion that makes horse-races.
learning, once begun,
develops its own momentum.
I am often asked how to apply
principles of good counseling in group settings. Good
question! Staying client-centered as a group leader is
more of a challenge. When you succeed, the payoff can be
better than when working with individuals. In the next
several Tips, I will address aspects of group work. This
Tip is an overview.
Advantages of groups:
can help more
people with your time.
support process is right there in the group.
has been shown to be more
effective. The American Dietetic Association’s
Analysis Library addressed this question:
“What is the evidence regarding the difference in
effectiveness for individual versus group-based
nutrition counseling?” The conclusion was that
group counseling was significantly more effective
than individual counseling.
may find it more
Disadvantages of groups:
energy from one person can bring down the group.
people’s needs will not be met.
will likely need to spend more time preparing.
Types of groups:
classes: These are groups of patients assembled to
impart information in an efficient manner. Typically the
only goal is education. Examples: A diabetes
self-management class that covers the basics for those
newly diagnosed or a onetime class to inform about a
program or procedure.
groups: These are typically groups scheduled on a
drop-in basis. Rather than making a commitment to attend
for a set number of sessions, participants can come once
or many times. These sessions are best run as
facilitated group discussions. The participants are
asked to generate the topics and substantially
contribute their own experiences to the information
sharing process. The leader’s role is to facilitate
the process and to provide professional advice only when
needed to correct misinformation. This process works
well in clinics where a group is assembled from the
patients who happen to come in that day. Support groups
for diabetes management, post-bariatric surgery or
dialysis fit this category. WIC programs around the
country have successfully adopted this approach.
behavior change groups: These are structured
behavior modification groups for weight management
and/or diabetes self-care that are commonly conducted
for research or treatment. They are often called
Cognitive Behavior Treatment. These groups include
elements of both processes above. Some education is
provided, and sections of time are spent in open
discussion of what is of concern to the participants.
They also create an experience for the participant and
encourage the behaviors known to support permanent
change such as self-monitoring, step-by-step shaping of
new behaviors, positive reinforcement and social
The next several Tips will address
group strategies, effective language, leader roles and
Facilitated group discussion:
to make nutrition education more meaningful through
facilitated group discussions,” R. Abusabha, et
al.; J Am Diet Assoc. 1999:99:72-76.
Group Discussion” training module, Arizona
Department of Health
WIC Parent Connections Video
Cognitive Behavior groups:
Weight Management Program;
LEARN Program for Weight Management, Kelly Brownell,
to list of Tips
A Random Collection of Strategies for Groups
cannot be solved at the same level
of awareness that created them.
good listener is not only popular everywhere,
but after a while he gets to know something.
Using participants’ names
(Tip #2, available in the Practice
Workbook, Vol 1) takes on particular significance in
groups. Learn names as soon as you can. Asking
participants to use name tags helps both you and the
other participants. For an ongoing group, participants
can make their own reusable tags as part of a group
icebreaker. Deliberately choose when to use a client’s
name. For example, use the client’s name when he is
having a side conversation and you want to draw him back
into the group or when you hear an important point that
you want to highlight.
It is not as simple to offer
choice (Tip #47, available in the Practice
Workbook, Vol 2) to a group, but it is just as
important when behavior change is a hoped-for outcome.
The leader can ask for input on room arrangement,
temperature, order of activities or anything else that
would not jeopardize the process if adjusted.
Individuals can also be given choice as to which group
to join (if there are several), how much to participate,
and which behaviors to work on in the coming week. If
food records are part of the group, the leader can ask
for input on what type of feedback each person finds
Working with outcomes
(Tip #29, available in the Practice
Workbook, Vol 2) is especially important in a group
setting because each member will have different
hoped-for outcomes. When people are clear about what is
important to them about a change, they are more apt to
do it. (Also see Tip #20, Unpacking Meaning, available
in the Practice
Workbook, Vol 1.) Here is a group activity that
encourages clarification of outcomes:
time (next spring, for example) when you have achieved
some of the goals you came to work on in this group. Jot
down what you expect/hope to experience then as a result
of making these changes you are working on. What is the
best part of having lost weight/better blood sugar
control/ being more active (or whatever it is you want
to change)? What do you imagine being able to do then
that you cannot do now? Write it down and then share
with the group. This activity can be done periodically
in ongoing groups to maintain focus on desired outcomes.
Groups can support a person’s hope (Tip
#68) for real change. Seeing other group members
make changes and get results can be motivating.
Exploring hoped-for outcomes as described above tends to
increase hope. In an ongoing group, one member may
experience a period of hopelessness.
The group cohesion and momentum of weekly
meetings can carry that member to a more hopeful time.
(Tip #38, available in the Practice
Workbook, Vol 2) enhances groups in several ways.
First, if you are fortunate enough to team-lead a group,
discuss who does the best job in the various leader
tasks and divide them up. For a long-running group, you
can take time off and let the group continue with the
other leader. If it’s a group you run over and over,
you can switch roles to reduce boredom and burnout. A
group also allows natural collaboration among members.
You can encourage this by affirming peer support when
you see it and by implying they are the most important
members of the group, not you.
your style to the group (Tip
#52) is one of the challenges and joys of group
work. Many aspects of style affect groups. Your high
energy, for example, can either energize a group or
discourage participation. Attend to the energy in the
room and adjust if needed. Sometimes groups get a little
too rowdy, and remaining calm yourself can calm the
group. Style can also refer to degree of formality,
intellectual level or amount of personal information
Careful use of humor
(Tip #30, available in the Practice
Workbook, Vol 2) can add to group cohesion. People
who have fun in a meeting are more apt to come back. Pay
attention to the responses to humor both initiated by
you and by group members. Some humor can be shaming or
offensive. In a class format, most of the humor comes
from you, so make sure your audience is with you. In
ongoing groups, ideally most of the humor will originate
in the members. Your role will be primarily to support
and monitor it.
The choice of whether
to weigh group members (Tip
#74) and how it is done have a significant effect on
the process. What experience do you want the group
members to have? Are you trying to emphasize lifestyle
change more than weight loss? If so, you may want to set
the tone by not weighing at all or by handling the
weighing privately or asking members to monitor their
own weight outside the group.
The same techniques that work when
you have little time (Tip #43, available in the Practice
Workbook, Vol 2) with an individual can work in a
group. Clarify the limitations, briefly bring up the
concerns from the group and agree on which topic or
topics will be covered. Cover the topic or facilitate a
discussion of the topic (depending on the type of group)
and share resources for more support and learning. For
an ongoing group, it might fit to promise to get back to
something important that came up and did not get
addressed. Include a moment of empathizing with members
about the limited time. For example: “It is
discouraging that with our busy lives we have so little
time to meet each week. (pause) Let’s see how much of
this we can address today.”
The most effective manner to provide nutrition advice in a group will depend on the type of
group. “Elicit/Provide/Elicit” (Tip
#59) works best with
specific topics, such as healthy snack ideas,
carb counting when eating out, or reducing sodium in
home-cooked meals, as opposed to more general goals such
as weight loss or blood sugar control.
As discussed in Tip
#67, how you respond to food
records is important. It can be more difficult to
adjust your stance in a group as compared with an
individual. For example, you may notice in an individual
session that the client uses the records to perpetuate
negative self-talk that does not seem to serve the
change process. You can question this and work to shift
the attitude, if the client agrees.
In a group, it is harder to catch what is
happening and to be aware of the members’ responses to
your written feedback. It can be useful to have a
discussion of how to best make use of records early in
the group process. You can mention that records are not
“homework” to hand in but a tool to help them
observe their behavior and more easily change it. Ask
them to let you know if your feedback is not working for
#56) can support and supplement what happens in
groups. Just as with individual sessions, they will be
most effective when embedded in a client-centered
process. Provide some materials that support the topic
and offer more optional ones. Explain what the resources
contain and are best used for while making it clear they
have the choice whether to take them. Invariably, some
in the group will love to take home materials while
others will prefer to learn verbally or go on the
Internet at home for more information. This gives
participants the choice of how to best use your
experiments (Tip #3, available in the Practice
Workbook, Vol 1) are one of the fundamental
techniques used in the health behavior change process.
In ongoing groups, members are asked to make a plan for
the week that allows practice of behaviors that will
head them in the direction of their goals. Calling these
plans “experiments” encourages careful observation
of what happens and a willingness to go “back to the
drawing board” if necessary. In a group, you can
support a tone of nonjudgmental experimentation among
the members. They learn to support one another to try
behaviors, learn from them and then adjust for the next
week as needed.
to change comes up often in groups. Review Tip
#55 for ideas on working with ambivalence to change.
When you reflect back ambivalence that you hear, you
bring attention to it and imply acceptance of
ambivalence as a normal part of the process of change.
For example: “On the one hand, Joe, here, really wants
to be more fit so he can enjoy his active vacations
without getting so stiff, and on the other hand, he has
not yet found a way to stay active week after week,
especially in the winter. Hmm. That does sound like a
dilemma. Does anyone else have a dilemma like that
holding them back? We can explore them more today.” A
group exercise can be for each person to develop four
lists: the positives about making a specific change; the
negatives about making the change; the positives about
staying the same; and the negatives about staying the
scaling (Tip #42, available in the Practice
Workbook, Vol 2) can be done over and over in an
ongoing group. The best time to ask group members to
scale their confidence is when a specific behavioral
change is being considered. For example: “So each of
you has come up with an exercise plan for this week.
Take a moment to think how confident you are on a scale
of 1 to 10, where 1 is not confident at all and 10 is
very confident that you will do this.” Ask members to
share their number. In a group, this scaling can tell
you fairly quickly whether some plans are too ambitious.
If anyone gives a low number, get a group discussion
going about possible obstacles. You could also ask if
the confidence number would be higher for a simpler or
smaller plan. Another way to use confidence assessment
in a group is to do this exercise: “Imagine it is
three months from now. You are doing this behavior
(i.e., going to the gym regularly or taking your lunch
to work). Looking back, how did you incorporate this
change? What supported you the most?”
is an integral part of change. Review Tip
#58 on the role of grieving in behavior change.
Groups can either support the grieving process or hinder
it. As the group leader, you can choose to notice and
remark on opportunities for grieving. For example:
“Joan, that sounds important. You said it is sad that
you are not able to turn to food for comfort since the
surgery. Does anyone else experience this?” Group
members will often try to minimize loss because it is
uncomfortable. This holds back the grieving process. You
can direct the conversation toward validating and
tolerating loss. “Nick, you seem to be saying it is
easy to eat so much less. I’m glad it is for you.
Let’s listen to what Joan has to say and find ways to
Taking care with the end
of group meetings (also see Tip #21, available in
Workbook, Vol 1) and the final end (Tip
#75) of an ongoing group can increase the power of
the group process to support change. Each session,
whether a onetime group or part of a longer process,
will be most successful if ended with a summary (Tip
#72). It can take just a few minutes or even less to
summarize what the group has done that day. Make sure to
include some of the input and ideas generated by the
members rather than summarizing your points. Ending a
long-term group takes more acknowledgment. It is useful
to begin to discuss the ending a few weeks early and ask
for input on how to celebrate and honor the work you
have done together. Ask the members to either write
and/or tell the story of their change journey. This
reinforces the process. Encourage them to include
something about the “next chapter” (i.e., how they
will continue these behaviors and maybe move toward some
more healthy changes).
to list of Tips
Attending to Language in Groups
If I could just find the right words…
With the right words everything could change.
For me, words are a form of action,
capable of influencing change.
Language has power. Your choice of words in a group can be either effective in moving clients toward healthy changes or can bring up their resistance. Your language also sets the tone for the group. Most of the language concepts addressed in other Tips apply to groups as well. Here I will show how they can fit. Refer to the listed Tips for more detail. Tip
#54, Watch Your Language, also summarizes many of these ideas.
Mirroring (Tip #6, available in the Practice
Workbook, Vol 1), reflecting back a person’s words, is one of the most powerful techniques you can adopt as a counselor. It has many useful functions in a group.
You can choose which words to mirror and thereby
highlight them for the others in the group. For example, a member may have gotten off track with his eating plan and realized this is because he stopped recording. When you reflect that back, “So, you learned the hard way how vital monitoring is,” you are reinforcing the lesson for him as well as for the others.
accepting environment (Tip #12,
available in the Practice
Workbook, Vol 1) supports the change process. You model acceptance for the group by mirroring. Reflecting all kinds of member statements, including the tough ones, can be difficult at first. It pays off. “You are frustrated at how long this weight-loss process takes.” When you simply mirror rather than make a judgment, you encourage all the group members to bring up their lapses and opportunities for learning. For example, instead of “That’s not good that you didn’t record for all the days this week,” you simply state what occurred: “There were two days you didn’t record. Would you like to explore what got in the way?”
Success at eating healthfully is best achieved by repeating a simple process over and over: getting
feedback and then trying new behaviors. Group members get concrete feedback such as weight, Hemoglobin A1C or other blood work, energy level, hunger and satiety, enjoyment (or not) of new foods, etc. They may miss seeing much of the other available feedback. See Tip
#29 (available in the Practice
Workbook, Vol 2,) Working With Outcomes, for more examples of outcomes to attend to. For example, a food record may show that on days someone exercised, he noted better mood or energy. You could say, “So exercise gives you a feeling of energy and better mood.” It may seem unnecessary to highlight this. But reflecting that out loud has a powerful reinforcing effect on that client and possibly on others in the group. In this way, your reflecting statement serves as the essential feedback necessary for the change process.
Reflecting can also offer a
reframe (Tip #10, available in the Practice
Workbook, Vol 1). It is common in weight-loss or other behavior-change groups for members to focus on the negative or to exhibit black/white thinking. These thought patterns make change less likely. Your reflections can open up thinking patterns. For example, a group member may say, “I’m so bummed that I didn’t lose weight.” If you don’t reflect at all, this negative statement hangs in the air and others may join in to complain. It may be tempting to try to “cheerlead” this person: “But you have made such great changes so far and have been losing so well so far. This is just one week.” Arguing like this is likely to bring up resistance. If you reflect with slightly different words, you can offer a reframe: “You are disappointed that this week the scale is not down.” Notice the slight shift in words that implies that it is just this week and that it is just the scale specifically. You rolled with the resistance while offering to reframe it. You could suggest he look at other ways to evaluate his week.
Avoiding the “Why” question (Tip
#17, available in the Practice
Workbook, Vol 1) is just as important in groups as it is in individual sessions. For example, consider the shift from “Why do you think you ate that cake?” to “What do you suspect was going on just before eating the cake?” Or “How could we help you problem-solve those situations?”
Attend to the use of the word “but” (Tip
#64) both when you use it and when group members do. Your shift to “and” encourages an accepting environment and makes it more likely the members will hear all of what you wish to say. For example, read these two statements used in a weight-management group: “You did really well keeping food records this week, but let’s take a look at the total calories” and “You did really well keeping food records this week, and let’s take a look at the total calories.” When group members use “but,” you can gently suggest they try saying it again with “and” or you can reflect back their statement and switch the words. The group members may not notice at first, but if you continue, they may notice and begin to shift their wording, too.
Humor (Tip #30, available in the Practice
Workbook, Vol 2) can help form a supportive environment in a group. Spontaneous humor from group members is the best way for it to get started. Watch carefully to make sure all the members look as if they are comfortable with the type of humor that emerges. If a few seem to respond poorly, you may need to request that the initiating members tone it down. If your style is to present information in a humorous way, go for it! Just make sure to notice the responses. It is not uncommon for members to enjoy the leader’s humor, but then get into a passive, listening mode. It may be necessary to tone down your humorous style to let members emerge more.
Imperatives (Tip #39, available in the Practice
Workbook, Vol 2) are statements such as, “You have to…” “You should…” or “You need to…” This wording is very likely to bring up resistance whether you use it or group members do. Word your advice with neutral statements of fact to be most effective. For example, instead of “You should record your food right after you eat,” try “We find that program members who record their food right after eating it are most successful.” One of the most powerful aspects of groups is the support and advice members get from one another. It is a great idea to wait to offer your suggestions on handling challenges and instead ask for input from others. Unfortunately, the members may share advice in an imperative style. They have not been trained to be as nonjudgmental as you. The next Tip will give ways to handle this.
Competence at asserting one’s needs is an essential skill for anyone wanting to make healthy lifestyle choices. Tip #48
(available in the Practice
Workbook, Vol 2) explores the role of assertiveness training in your work. If time allows, a lesson in assertiveness can be included. Group members can then be encouraged to assert their needs in the group and to practice in the world.
Questioning style matters! (Tip
#60) Open-ended questions posed in a group encourage active participation and a problem-solving mentality. For example, “Think about your week coming up. What do you see as the challenging situations? Picture them in detail. What strategies have you learned here that you can picture employing?” If you have limited time to share each person’s story, you can ask group members to think and/or write for a few minutes. After you present information, elicit feedback (Tip
#59) with an open-ended question to bring the group back to an active role. For example, “So what do you make of all that?”
#63) is one of the most valuable strategies you can use and it takes so little time. For example, a member may describe an effective strategy while telling about her week. Reflecting that strategy with a positive tone both affirms that client and highlights it for the others. “Joan, what a creative idea to combine your walk and time in the park with your grandchildren!”
Group members will voice change talk (Tip
#69) throughout the session. Reflect as much of it as you can for the benefit of that member and the others. When you wind up a group session with a summary, include not only your points but also what you have heard from the group, including problems, solutions and some of the change talk.
As the group leader, you are creating an experience for the members. What kind of experience do you want them to have? Choose language to support the ideal experience for change.
to list of Tips
That Arise in Groups
Some people regard discipline as a chore.
For me, it is a kind of order that sets me free to fly.
Behind every difficult person or situation is
a blessing just waiting to be revealed.
The best way to avoid problems in
groups is to set things up carefully from the beginning.
This is often learned by experience. Running a group can
be pretty bumpy the first few times before you learn
what to do to set the tone for a healthy group process.
These ground rules include:
attendance and assignment expectations
and acceptance of everyone
Strong feelings, embarrassing behaviors and life events
often come up in groups. We, as health professionals,
are familiar with the rules of confidentiality. We know
that they provide a safe environment in which to explore
new behaviors. We cannot assume that group members
understand this unless we explicitly state the rules and
then reinforce them if necessary. Here’s an example:
“It is important that you all feel safe here to share
important things that may come up in your effort to
change your eating habits. There are certain rules that
are well known to support this safe environment. First,
it’s fine to share outside this group all you want
about what you have learned and what you are working on.
The stories and struggles of others are not yours to
tell outside this room. Second, some of you may run into
each other outside here. You don’t know if your fellow
group member has told others in his life about the group
and whether he is willing to connect in social settings.
So, hold back unless you know for sure that it is OK.
Third, if you see group members outside here and see
behaviors that you think are important to our work, it
is not your job to report them. We’re not cops. Each
member is responsible for his own behavior. Are there
any questions or concerns about these safety rules?”
For more on Confidentiality, see Tip # 45.(Practice
Workbook, Vol. 2)
socioeconomic, age and gender differences:
Acknowledging these differences can go a long way toward
making the group function smoothly. For example, if you
know you have a diverse group, a statement at the first
meeting will allow you to bring it up later if it
becomes problematic. “Boy, we do have a wonderfully
diverse group here, don’t we? Sometimes it’s tricky
to keep from offending someone when we come from such
different backgrounds. Let’s keep an eye out for ways
to include everyone. I’ll check in with you in a few
weeks to see how it’s going.” If you notice the only
male in a group looking uncomfortable at times, bring it
up and ask for help. “I wonder if John feels a little
left out when we talk about girl stuff. Does anyone have
any ideas how we can include him more?”
If the suggestion to steer away from
gender-specific topics comes from someone in the group,
it will more likely be accepted.
needs: Make clear up front what members can and
cannot expect from this group or program. Review the
advantages of a group (cost, learning from one
another’s experiences, support from peers, etc.) and
mention the downside of possibly having to sit through
parts that don’t fit their particular needs. The idea
of “take what works for you and leave the rest” is a
useful reminder. Many programs include an individual
screening session first where expectations can be
brought out and clarified. If additional needs emerge,
make a referral for more support or therapy. During a
session, if issues come up that are best addressed in
therapy or another setting, make that suggestion. For ideas about language to use when making
this referral, see Tip
#31, Nutrition Therapy and Psychotherapy: Where Are the
Edges, in Practice
Workbook, Vol. 2.
also reminds the others in the group that they may not
get all their needs met through the group.
off topic is a common challenge, especially if you
have a very engaged or social group. Part of a
leader’s job is to guide group discussion. This can
include steering it away from controversial areas, such
as politics or religion. Affirming first can help you
then redirect: “Wow! You guys have loads of energy
tonight and clearly care a lot about these issues. We
have so little time here; I hope we can stick with what
we had planned to cover today.” Sometimes groups get
off topic because the planned topic is uncomfortable. If
you suspect this is the case, express empathy and offer
choice before directing back to the topic: “I know
that it is uncomfortable to talk about the feelings that
lead to overeating. Let me remind you that no one is
going to make you do anything different until you are
ready. It’s your choice. Maybe you could join the
discussion as an exercise in thinking about change
without making any commitments.” Tip # 15, Staying on
Workbook, Vol. 1) has some more ideas.
Other group processes that are hard
to manage include members who complain about other
people to deflect thought and action around their own
behaviors. This creates a negative
atmosphere. Containing this process can support the
other members who are ready to change. The simplest way
to contain is to briefly reflect what you hear and then
redirect. Wording your reflection in the form of an
#63) makes it easier to hear. If you suspect that
the complaints exist at least a bit in several others,
your reflection will validate them as well. Sometimes
complaints are directed to others in the group.
Including a rule about respect and acceptance at the
beginning of the group will make it easier to refer back
to this if things get ugly. For example, “Everyone’s
ideas and contributions are to be accepted. Remember
that ground rule about putting down others? We’re all
doing our best here.”
In extreme cases, a member may be
so disruptive or negative that you will ask that member
to leave the
group. This is best done individually and in the
context of “not the best group for you at this
time.” If possible, ask for support from someone else
in your organization. You
may find some useful language for this in Tip
#75, Ending Treatment. Again, clear ground rules for
the group are useful because you can then rely on them.
Some people attend group meetings
regularly and are not
making any changes. How you handle this will depend
on the type of group and its effect on the others. See Tip
#57 for some ideas. If you are trained in
Motivational Interviewing or have someone on your staff
who is, an individual interview is an effective
intervention. The interview would follow the pattern of
open-ended questions to elicit change talk, then
feedback presented in a factual manner (for example,
weight, A1C and/or food records) and then eliciting and
reflecting discrepancy between goals and current
behaviors. The final minutes would be spent developing a
plan and asking for commitment. If the person is able to
move forward, this procedure will support that process.
Some will not respond positively because they remain in
the early stages of change. If the person seems to find
the group supportive in some way and is not disruptive
or holding others back, you may choose to simply let her
You may sense that a group member
is lying about behaviors or that food records are not believable. In
Tip #36 (Practice
Workbook, Vol. 2), I explore various reasons for
lying and language for addressing it. Bringing it up in
the group setting is tricky. Being confronted with lying
in a group is very shaming. Shame does not help people
move toward positive change. Individually bringing it up
with curiosity is more apt to prompt acknowledgment if
the person is able and ready to. The format of a
motivational interview is a good approach.
members is often a struggle. A combination of
carrots and sticks works well. An
example of a “carrot” is to inform the group that
your experience is that those who attend all sessions
are the most successful in attaining their goals. Some
programs also offer financial or other incentives for
good attendance. A “stick” would be a rule such as:
Members who miss more than one session out of six will
need to leave and have the option of joining a group
forming in the future. Research on Motivational
Interviewing has clearly shown that individual
interviews conducted within MI guidelines at the
beginning and about every two months improve both
retention and outcomes. Even taking a moment to call or
talk for a moment after a session with those who seem to
be wavering can help. Make sure to elicit their concerns
and listen carefully.
Some of the most common problems
are getting participation from quiet
members and dealing with monopolizers.
Both of these can be handled with similar approaches.
First, find at least one activity each session that
requires everyone to participate, such as going around
and asking the members to share something they are proud
of so far or to contribute an idea to that week’s
topic. The process of affirming is useful both to
encourage quiet ones and to contain talkative ones. Here
is an example for a quiet one: “Jane, you have
contributed some great ideas other weeks. What are your
thoughts on this topic?” When one person is going on
and on: “Joe, thank you for your ideas (or for sharing
your concerns). I’m sure others have things to
contribute, too.” A little empathy and gratitude go a
long way. For example, “I know it’s difficult to
keep quiet when you have so much to share. We appreciate
your letting others have time, too.”
that come up is one of the leader’s jobs. Your
“righting reflex” (Tip
#65) is triggered when you hear something
“wrong” in a group. It is tempting to jump in and
correct it right away. This is likely to elicit
resistance and begin an argument. Sometimes myths or
incorrect information come from outside the group (“My
doctor said it’s OK”).
Here is a format to follow:
something. “You’ve obviously thought a lot about
this.” Or “You seem to like having the latest
information,” or “Thank you for bringing up this
topic. I know others have heard this same thing.”
what others think FIRST (unless you know that no one
in the group has the correct information). In many
cases, the group members will have the facts and you
may only need to affirm them or add a little bit
you have facts or ideas that have not come up, ask
permission to provide them. “I have read the
research on that. Would now be the time to share
it?” or “This program has specific
recommendations based on research and the experience
of others. Would you like to hear it?” or “The
American Heart Association has come up with clear
recommendations for lowering your risk.”
You may even use humor if it fits your style.
“Well, let’s see. My job here is to give the
party line based on the latest science. Ready for
your view in a factual manner. “The WIC Program
recommends waiting until 6 months of age to add any
foods besides breast milk or formula. Babies who are
given other foods earlier have more digestive
problems and may get allergies.”
“It is very common to become protein
deficient after bariatric surgery. Starting the meal
with the protein food makes it easier to get enough
protein.” (See Tip
#59 for more on using neutral language that will
not trigger resistance.)
Group members can fall into the
“righting reflex” trap as well. They may feel they
are simply offering support and advice. When they use
“imperative” language, it may turn off other
members. For example, “You just have
to stop eating that stuff” or “I’ve started
walking at my lunch hour. You should
do that.” Such wording will as likely be met with
resistance when group members use it as when you do. As
the leader, you can model more respectful language.
“I’m glad that works so well for you, and each
person gets to pick and choose which strategies will get
them to their goals.”
Myths and wrong information are one
of the disadvantages of client-run
groups. There is no professional to provide the
research-based information. Some organizations choose
not to allow groups to meet without a professional
leader for this very reason.
Group members may challenge
your expertise. In Tip #32 (Practice
Workbook, Vol. 2), I explore what may be going on
when clients challenge us and I provide guidelines to
follow. This is particularly difficult in a group. You
may feel attacked and embarrassed in front of the group.
If you can catch yourself before you feel ashamed, bring
up your curiosity. What might be causing this person to
challenge you? Maybe she is frustrated about her lack of
progress and wants to blame you or just feels more
comfortable when she is the most knowledgeable one in
the room. Even if you are not able to elicit what is
behind the challenge, maintaining your curiosity may
help you stay calm and professional.
It is common for group members to
ask the leader personal
questions such as “What do you eat?” “Do you
have diabetes?” “Have you had bypass surgery?” The
same approach is used in group and individual sessions.
Tip #18 (Practice
Workbook, Vol. 1) has a full discussion of this
important process. Briefly, the format to follow in
response to these questions is to bring out where the
question comes from (i.e., what the real question is),
and then respond to that real question and thereby
direct the conversation back to the person asking the
question. This process is not easy to learn and takes
practice. It is especially hard in a group because as
the leader you may feel in the spotlight. It’s hard to
think quickly on your feet. Most leaders find that if
they routinely use themselves as an example, or discuss
their own health or weight history, this invites more of
these questions. This seems particularly true in a group
setting. It then becomes easy for a group session to
become about the leader instead of about the members.
Look for consultation and support.
These problems that arise in groups are difficult to
address. Find someone to talk it over with. The goals of
these consultations are to support you and the
development of a plan of action.
to list of Tips
Our Role in Groups
Leadership is getting someone to do
what they don't want to do,
to achieve what they want to achieve.
A facilitator’s job is to support
everyone to do their best thinking.
The approach you take as a leader
has a profound effect on group members and on the
outcomes. Each leader develops her style based on
training, personality, comfort and feedback. It is
useful to have the flexibility
to shift styles depending on the setting and group. For
example, a onetime talk to a group on a specific topic
may demand an entertaining and educational stance while
leading an ongoing behavior change group will require a
gentle, facilitative manner that elicits group
participation. Over time, leaders can stretch into new
styles as they collect feedback and practice.
This Tip focuses on the leadership
roles in behavior
change groups. These
groups call for you to shift into various roles
depending on the need. (In a didactic class, you will
stay primarily in an educator role.) Overall, a group
leader who remains both client-centered and gently
directive will be most effective. Some roles support the
behavior change process and some thwart it. Tip #25 (Practice
Workbook, Vol. 1) explored the various roles you can
take in counseling an individual. As a group leader, you
can be called on to assume an equally wide range of
of facts/provider of information
to guide and structure the sessions
model for respect and acceptance in sessions
can be more of a challenge in a group. Ask yourself this
useful question: Who is the expert? You or the group
members? And an expert on what? A successful leader is
expert on the process that will most likely lead to
success for the members and on the content area. For
example, the expertise may include the science of
nutrition and weight management and what research says
is the most successful way to run weight management
groups. The successful leader allows group members to be
the experts on their own lives and how to make the steps
toward their goals.
A successful leader strikes a balance between maintaining
control of a group session while not being the focus
herself. This is an art that takes lots of experience.
The roles listed below are tempting to take in a group.
However, they tend to focus the attention of group
members on you and therefore detract
from each member’s own behavior change process.
police/confessor/judge: Accountability is a useful
function of behavior change groups. The skillful
leader encourages members to be accountable to
themselves first and to their peers rather than to
The support members get from one another is more
effective than any cheerleading you can do. What
positive feedback you give is most effectively
directed to encouraging the processes that will
likely lead to success (i.e., keeping food records)
rather than to choosing specific foods.
When you find yourself debating, you are
encountering resistance. Continuing to push simply
increases the resistance. (See Tip #9 (Practice
Workbook, Vol. 1) for more on this.)
comedian: A leader with a naturally outgoing
personality finds it easy to be fun and engaging in
a group. For educational programs, this works very
well. The participants will enjoy themselves and are
likely to remember the content. However, when
behavior change is the goal, an extremely
entertaining leader detracts from the process the
members must move through. Toning down an outgoing
manner for these groups is part of staying
model for healthy behaviors: Many health care
professionals choose to work in preventive programs
because of their own experience making healthy
changes. Using oneself as an inspiration to others
can work at times. The downside is the focus remains
on the leader, reducing the emphasis on each group
member and the significant changes each needs to
The goal of keeping the focus on
group members will affect the leader’s decisions about
how much is
appropriate and effective to disclose about herself.
Tip #1 (Practice
Workbook, Vol. 1) addresses many of the issues that
arise when you reveal things about yourself to your
clients. Everything a professional reveals has more
force than that revealed by group members and so should
be revealed with great care. Most groups respond well to
leaders who reveal some light things about themselves.
Experienced leaders learn to reveal simple things that
do not get too close to the topic at hand. For example,
a leader may mention a pet or a troublesome car but stay
away from her own food choices or experience with weight
management. This has the effect of personalizing the
leader without the group becoming about her issues.
Again, these revelations are powerful; a little bit goes
a long way.
Handling group members who ask the
questions is addressed in Tip
#87. Sharing anything about yourself that relates to
the topic of the group invites personal questions. If
the only things you share are unrelated and confined
mostly to the lighter moments at the beginning and end
of a session, you will likely not get personal
Long-term groups may get pretty
deep into psychotherapy
issues. Decide how much of this you will attempt to
address. Some programs have a social worker or
psychologist conduct some of the sessions. In these
situations, you can defer deeper issues that come up to
the weeks when those professionals lead the group. When
you don’t have this team in place, find resources to
refer members to.
In groups that are less structured
such as drop-in support groups or WIC groups, your role
will be as a facilitator of the group discussion. See the resources listed in Tip
#84 for more detail on the process of facilitated
group discussion. This process can also be seen as group
sharing or brainstorming and can fit as a section of a
more structured behavioral group. Overall, your role is
here one that supports all group members to do their
best thinking. This means guiding the process and may
A note about your growth:
Leading groups is both challenging and gratifying.
Skillful group leading takes years of experience to
master, and there is always room for growth. Consider
searching for feedback. This might take the form of
written evaluations by group members, asking a colleague
to sit in and make suggestions afterward, or recording
When running your first few groups,
you should find someone to review with so you can learn
from your mistakes. As you become more experienced, you
will need a mentor
less often. However, it will always be useful to talk
with someone about the problems that arise. Have a
mentor or colleague “on call.” This will make
burnout less likely and support your process of skill
to list of Tips
Tip # 89 Phone
For me, words are a form of action,
capable of influencing change.
Desire, ask, believe, receive.
Stella Terrill Mann
In this age of multiple forms of
electronic communication, the traditional office visit
is not the only way to provide nutrition counseling.
E-mail, phone, voice mail, webcams, chat rooms, blogs,
text messaging and Twitter are all ways to communicate
with clients. This Tip addresses the use of phone
sessions used either alone or as an adjunct to office
Advantages of phone counseling:
Clients do not need to travel. This
saves time and gas money and is more convenient.
This is particularly useful for clients who live in
remote areas and are not able to access professional
nutrition counseling in person.
You may save on office expenses and
professional clothing. If all your work is by phone,
you do not need a professional office and you can
work in casual clothing (or pajamas).
You may be able to charge less for your services
because of these savings.
Appointment times can be more
flexible and spread throughout the day since you do
not need to be in an office.
Geography doesn’t matter! It is
possible for you to work with people all over the
world. If you have a niche specialty, such as PCOS
or food allergies, by phone you have access to a
much larger clientele than you do in your local
It is “green” since gas is saved
and all records and handouts can be electronic.
If the client has a question about a
specific product, you can ask him to get it and read
the label to you.
Some people are more relaxed on the phone. They may
share more openly than in person.
You could choose to allow clients to
call you spontaneously when a question occurs to
them or they need support to make positive choices.
If you get bored easily in your
work, having some sessions in person and some on the
phone may be more interesting for you.
You can continue to work with a
client who moves. Many dietitians who treat eating
disorders find this works well when a client goes
away to school or moves to another state. A
long-term trusting relationship plays an important
role in recovery. If the client moves, she
does not need to get to know a new dietitian. This
works well only if the client is fully engaged in
recovery and you have developed a trusting
relationship. For clients still in some denial, a
referral will be more appropriate.
Since the client does not see you,
any issues that might arise about your size or shape
will not come up.
For some low-literacy clients who
are stronger in verbal skills, more frequent,
shorter phone calls can be more effective than
longer office sessions.
Voice messages can be a useful
addition to in-person sessions or phone sessions. A
client can give you quick updates or you can leave
answers to simple questions.
Disadvantages with some suggestions
Many insurance companies will not
cover counseling that is not in person. You can
address this by being explicit about it and offering
choice. For sessions the clients wants covered
by insurance, they come into the office, and for ones
they are willing to pay for, you offer either office or
phone sessions. For clients who want more sessions than
are covered by insurance, you can spread out the
in-person paid sessions and alternate with phone contact
that is billed separately. Consider package rates that
include a variety of ways for clients to access your
You may find yourself making the times so
flexible that your life is disrupted and work time
bleeds into off time. You then will likely not provide
the best service. Set the limits you need to do your
best work and to care for yourself. Having a separate
office phone number is essential. Even if it rings in
your home, answer it only at times that you are prepared
to work. If you don’t have an office, it is still
appropriate to have a separate phone number for
professional calls, even if it is a cell number. For
more on setting limits see Tips #21, Time Boundaries,
and #22, Burnout (Practice
Workbook, Vol. 1.)
Clients might take advantage of phone access to you.
It is a challenge to provide what each client needs
while still making a living and not becoming resentful.
The informality of phone sessions may make this more
challenging. When you begin to feel resentment toward a
client for the time she takes, this tells you it is time
to set more limits. Over time you may choose to set
specific limits on the number of random calls.
While it is great to be able to work
wherever you are and in whatever clothing you feel like
wearing, this informality may affect your
professionalism. It may be tempting for you to do
things that you would not do with a client in the
room, such as check e-mail. To avoid this, set up your
space to support you. For example, sit in the same chair
you do for office counseling, or if at your computer,
open only the programs necessary for this client and
have visible only written materials for this client. I
find it useful to have a picture of the client visible.
Some people are just not “phone
people.” They are uncomfortable using the phone
for anything beyond short, concrete needs. If you are
one of those people, phone counseling will likely not
work for you. Some clients will just not be able to warm
up enough to use the phone effectively. It is useful to
discuss this with clients on their initial contact with
you. You could ask: “How do you feel about having long
phone calls? Are you someone who likes to talk on the
Sometimes cell phones cut out or voice
quality is not ideal. There may be distractions on
the client’s end such as room noises, dogs, or family
members. You may insist that a land line be used and
that the client find a quiet time and room where he will
not be interrupted. You can set expectations for phone
sessions, just as you might insist children be left at
home when a client comes to your office.
You may need to see the client to
conduct a visual assessment or you may need to weigh
the client or get other measurements. Any time you
feel you are not able to do an adequate job because of
these limitations, you can insist on at least one office
visit. Some clients may be able to weigh themselves and
report to you. This is generally not a good idea for a
client with an eating disorder or a weight-management
client who is overly focused on the number on the scale.
It can work with a client with whom you have an ongoing
trusting relationship and who is in the final stages of
recovery. The use of blind weights in nondiet or
eating-disorders work would be possible only if the
client could be blind-weighed by a third person who
would report to you. See Tip #74
for more on blind weighing.
You don’t have the visual feedback
that you would in an office visit. For example, a client
may not like one of your suggestions. In person, you
would be able to pick this up from nonverbal cues and
switch to open-ended questioning. To effectively track
your client’s responses with no visual clues, check in
more often about the direction you are taking, the
client’s goals, what she wants, and what she means.
Keep checking in! When doing a piece of education, stop
and ask for response often. You may feel as if you are
working harder. It is certainly different from
one-on-one and takes practice. Remind the client that
you cannot tell whether she likes your ideas unless she
says something. Some clients will give voice clues, but
most will not. See Tip #4 for more on asking for
Workbook, Vol. 1.)
Time can feel less structured than
in an office visit where your client may be aware of the
next client in the waiting room. Structure phone
sessions more carefully than office sessions. For
example, you might divide up the time and set a certain
number of minutes reviewing the last week and food
records, then a section for education and then begin
talking about goals by a certain number of minutes from
the end. With new clients, it may be necessary to be
firm about this structure until they get used to it. For
more on setting time limits, see Tip #21 (Practice
Workbook, Vol. 1.)
Clients may be more apt to forget
calls. If you call them, they may be caught off
guard. One way to avoid this is to have clients call
you. This is similar to an office visit where the
clients are expected to remember the appointment and get
there. Treat phone sessions as you would office visits
with the same no-show or late-cancellation policies.
Some clients will want a text or e-mail reminder,
depending on their favored form of communication. For
more on this, see Tips #34, Discussing Fees (Practice
Workbook, Vol. 2), and #51,
Setting Professional Limits Around Fees.
Phone sessions can be taken less
seriously. Many people are accustomed to talking on the
phone while doing other things such as cleaning dishes
or going for a walk. Of course, a client would not do
this in your office. You may be able to tell when a client
is multitasking because she will miss some of what
you say. Setting ground rules may help. For example:
“I find it is most effective when my clients set aside
the time for our phone session and sit down with nothing
but their notes in front of them.” The request for phone sessions when it is not absolutely necessary could
signal a lack of commitment to this important process of
The client may not be prepared for
the call. Of course, this can happen at office sessions
as well, but may be more common on the phone because
phone calls take less action on the client’s part.
Defining the sessions and asking for specific
preparation from the client may help. For example: “So
next time we have agreed to spend some time on portion
sizes and you are going to make the call in your kitchen
so you can measure your plates and glasses.” You may
need e-mailed food records or for the client to do some
reading. When clients don’t do the preparation you
expected, revisit their readiness to change (Tip #7, Practice
Workbook, Vol. 1). You may also find it useful to
open a discussion by asking, “May we review how we are
doing these calls to make them most effective for
When you are not in the same room
with your client, you cannot both look at a piece of
paper or food model at the same time. If you use food
records and/or handouts a lot in your work, you may need
to require your clients to be at a computer with a good
Internet connection during the call to allow you to
review records and to send them materials by e-mail.
In summary, your role in phone
counseling is not exactly the same as in office
sessions. You may find you need to deliberately “shift
gears” if you do both office and phone sessions. Find
what works to support you to stay in your counselor role
while on the phone and stick with it. Remind yourself to
provide more structure and ask for feedback. It is OK to
admit to clients that you are experimenting with phone
counseling and want feedback about how it is working (or
not) for them.
to list of Tips
The cure for boredom is curiosity.
There is no cure for curiosity.
Replacing judgment with curiosity
is a key
element in becoming unstuck.
state in which you want to learn more about
emotion related to inquisitive behavior
tendency to ask questions, investigate or explore
desire to know what is happening or has happened
It is the “cure” for boredom,
as in the quote above.
It is also a cure for anxiety, stuckness and
It focuses attention on the subject of the curiosity. When we are
anxious about the unknown, it is useful to focus
attention on what we do know and we can do this with
curiosity. Curiosity, then, has the effect of teasing
apart the elements that contribute to anxiety or
stuckness or feeling overwhelmed. (See Tip #33, What We
Can Do and What We Can’t, in Practice
Workbook, Vol. 2).
and curiosity are unable to exist together. When
we’re overwhelmed with anxiety or fear, curiosity is
absent. Conversely, when we follow our inquisitive
nature, fear rarely comes up. We can use this dichotomy
with our clients. For example, when we direct our
clients’ attention with curiosity to the tastes and
textures of foods, they let go, even if briefly, of an
over-focus on calories or fear of gaining weight.
Our natural curiosity comes out when we meet a new client. We tap into this as we explore such
things as what this person needs from us, his
understanding of his condition and what is most
important to him. Tip
#20, Unpacking Meaning, (in Practice
Workbook, Vol. 1) has more detail on this process.
It can be challenging to tap back into this curiosity
periodically with an ongoing client. We may think we
know all about this person and what makes him tick.
Well, we don’t. There is always more to discover. With
clients, shift back over and over into that place of not
knowing. (See Tip #66,
What You Don’t Know Can Help You.)
Many of our clients are ambivalent
about making the changes we recommend and so get
they don’t know what keeps them stuck. Eventual change
emerges when the many elements of the ambivalence are
examined and accepted. We invite our clients to do this
by steadfastly maintaining a curious stance and letting
go of the need to “fix” it right away. For more on
this process, see Tips #55,
Working With Ambivalence to Change, #35, What to Do When
Stuck (in Practice
Workbook, Vol. 2), and #57,
Steady Clients Who Aren’t Making Changes.
Curiosity has the effect of
encouraging acceptance of what is true. A basic model for changing troublesome
behaviors is to accept the impulse behind the behavior
while still wishing to decrease the behavior.
Monitoring the behavior with curiosity to learn more
about the impulse implies acceptance of it. (See
Tip #12, The Power of Acceptance in Practice
Workbook, Vol. 1)
Counselors can adjust
their language to encourage a process of curiosity.
Using curious language with a client who is stuck in a
rigid way of looking at something reframes the
situation. (See Tip #10, Reframing, in Practice
Workbook, Vol. 1)
“Let’s remain curious about
“Imagine with me...”
“Hmm, that makes me curious
“Would you be willing to
explore that more with me?”
It is tricky when clients ask us personal questions or challenge our expertise or ability to help
them. Our defenses come up, and we want to defend
ourselves or argue or make excuses. These are not
professional responses and have the effect of digging us
in deeper. Hard though it may be, taking a deep breath
and responding from a stance of curiosity is most
professional and useful. Tips #18, Personal Questions
Workbook, Vol. 1), and #32, When a Client Challenges
Your Expertise (in Practice
Workbook, Vol. 2), have examples.
Another time to bring up your
curiosity is when you are getting
feedback on your work. This may include your annual
performance evaluation or listening to a session
recording (see Tip #73)
or reviewing customer service feedback cards. It is easy
to get defensive or feel shame in these situations. The
feedback will be most useful when you approach it with
open curiosity. It is always up to you which pieces of
feedback you choose to integrate as you grow.
is least apt to happen when someone is feeling judged
(or judging himself). “Why” questions are usually
heard as judgment. Even when our question comes from
genuine curiosity on our part, the client feels it as a
judgment. When we reword our questions to “How…”
and “What…” the client’s curiosity is elicited,
too. (See Tip #17, available in Practice
Workbook, Vol. 1)
Our natural curiosity leads us to
ask questions. This is well and good. As professionals,
our curiosity is directed to the benefit of the client.
It may be tempting to ask questions
that are of interest to you that do not further the
client’s needs. For example, your client refers to a
favorite restaurant. You
like eating out, so your curiosity causes you to ask the
name and location. This would be completely appropriate
in conversation with a friend. It does not serve the
client, so you instead ask questions that direct the
client toward her goals. For example, “Would you like
to discuss how to eat out healthfully?” or “How
does this place compare to other restaurants for finding
the foods that work for you?”
to list of Tips