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Counseling Tips for Nutrition Therapists Series
2009 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:
                  © 2009 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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  View Table of Contents

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Tip # 79   Choice Points in Your Career (1/1/09)
Tip # 80   Pushing Your Skills Envelope (2/1/09)
Tip # 81   How to bring Up Tough Stuff (3/1/09)
Tip # 82   Issues of a Home Office (4/1/09)
Tip # 83   When You Make a Mistake (5/1/09)
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 (10/1/09)
Tip # 89   Phone Counseling (11/1/09)
Tip # 90   Curiosity (12/1/09)

Tip #79  Choice Points in Your Career

Follow your instincts.
That's where true wisdom manifests itself.
Oprah Winfrey

It is easy to say No, when
there is a greater Yes.
                    Steven Covey

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 family.

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 and values.

Develop a list of values. Here are some questions to get you started:

• How 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?
• Do you prefer working with clients/patients one-on-one or in groups? 
• Do you prefer counseling clients in a continuing relationship or only once?
• What about the independence of your work, the amount of supervision you thrive with, the amount of collaboration with colleagues, etc.?
• Do you want to be pushed to continue to learn and upgrade your skills?
• Do you want a position that includes complex, academically challenging cases?
• Is it important to you to work in a well-respected institution?
• How important is the ethical conduct of co-workers and supervisors?
• Is variety in your weekly duties a must?
• Is giving back to your profession important to you?
• How much do you care about the length and type of commute?
• Do you want opportunities for research (your own or as part of a team)?
• Do you crave a boss or mentor you can learn from, or a boss who is there and responsive only when you have a need?
• Do you want opportunities to teach (medical students, nurses, college students, dietetic interns, etc.)?
• What age group and medical conditions do you prefer to work with or do you prefer a big range?
• Do you want to get into a new area of practice?

If you take on consulting work, you might consider:

• What is your bottom-line hourly rate (including travel time and expenses)?
• Will this contract likely lead to more of the work you like?
• Will it be necessary for you to let go of some other work to take this on?
• Does 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 this.

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:

• No more than 20 minutes from work to my daughter’s day-care site – A
• Colleagues in same location that I can look up to and learn from – B
• Working with pediatric population – A
• Supervise RD interns – C
• Employer that understands needs of my family and will allow time off if I need it – B
• Position where I need to continue to learn and stay up to date on research – B
• Employer who encourages involvement in professional groups – B
• Continuing-education costs paid for – C
• Includes some work 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:

• You get offered a job at a prestigious hospital, which feels good to your ego, but this is not on your list of values.
• The pay you are offered is much more than you had anticipated and you allow that to override some of your other values.
• A 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.
• You 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.
• Gratitude 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 for you.

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.

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Tip # 80 Pushing Your Skills Envelope

I am always doing that which I cannot do,
in order that I may learn how to do it.
Pablo Picasso

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

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 interlocked fingers.  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?  Difficult?  Wrong? 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 processes.  It 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:

• Including more open-ended questioning
• Remaining silent after an open-ended question and allowing a client to think and respond
• Including more affirming statements
• Reflecting out loud rather than just in your head
• Stopping to ask your client for direction in a session
• Summarizing the change talk you have heard
• Holding back a tendency to self-disclose
• Asking 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 be pushed

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Tip #81 How to Bring Up Tough Stuff

Our lives begin to end the day
we are silent about things that matter.
Martin Luther King Jr.

Instead of waiting for the perfect opportunity,
I should work toward a realization that
every opportunity is perfect.
Suzan-Lori Parks

No matter your work setting, there will be times you need to bring up a tough subject with someone.  For example:

• Your client does not appear to want to hear something you believe is important for her (or a family member’s) health.
• You 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.
• When you have limited time to convey very important information. 
• When an employee 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 format:

1. Bring 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 OK?”

2. State 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 three-item statement:

• Attention-getter: “This number here (HgbA1C) shows us if over the last month damage is happening in small blood vessels in the eyes and kidneys.  
• Factoid: “This number is very high and tells us that your average daily blood sugar is well into the risky zone.”
• Offer 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.”

3. Elicit 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?"

4. Listen.

5. Summarize 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 clinic:

• Ask permission: “May we talk for a few minutes about what you are putting in your baby’s bottle at night?”
• Attention-getter: “I can see that you care very much for your baby and want to be a really good mom for him.”
• Factoid: “Sweet beverages in a bottle at night cause teeth to rot.”
• Offer hope/instill confidence: “Babies easily get used to plain water in the bottle or a pacifier.”
• Elicit a response: “What is your response to this information?”
• Listen.
• Summarize: “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?” 
• If 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 satisfying, talk it out with someone.  Remind yourself you did the right thing even if the client did not thank you or respond as you had hoped.  Don’t 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.

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Tip #82 Issues of a Home Office

Begin somewhere; you cannot build 
a reputation on what you intend to do.
Liz Smith

Some people regard discipline as a chore. 
For me, it is a kind of order that sets me free to fly. 
Julie Andrews

Feeling safe does not mean we have no fear. 
It just means we have some confidence that 
we can deal with what scares us.
Thom Rutledge 

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. 

• Professional confidentiality 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.

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Tip #83 When You Make a Mistake  

Humility is wisdom.
Shame is not.

 Thom Rutledge

 Give me a fruitful error any time,
full of seeds,
bursting with its own corrections.

Pareto

Nobody’s perfect. We have all goofed at times and regretted something that cannot be taken back. Some examples:  

• You gave the wrong information to a client.
• You double-booked or missed an appointment.
• After a session, you realize that you missed an important piece of education.
• There was a misunderstanding about appointment time, length, fee, expectations or your policies.
• Confidentiality was breached.
• You 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 trauma (Tip #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.

Forgive yourself:

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.

Forgiveness 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.
Joan Borysenko

The man who makes no mistakes does not usually make anything.
Theodore Roosevelt

Striving for excellence motivates you; striving for perfection is demoralizing.
Harriet Braiker

When 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.
Barbara Bloom

We may in fact disappoint ourselves, may not meet our own expectations, but we do not cease to be a friend to ourselves.
Sharon Salzberg

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Tip #84  Working With Groups: An Introduction  

It were not best that we should all think alike;
it is difference of opinion that makes horse-races.
Mark Twain

Self-initiated learning, once begun,
develops its own momentum.

Ray Hartjen

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:

• You can help more people with your time.
• The powerful social support process is right there in the group.
• It has been shown to be more effective. The American Dietetic Association’s Evidence 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.
• You may find it more fun.

Disadvantages of groups:

• Negative energy from one person can bring down the group.
• Some people’s needs will not be met.
• You will likely need to spend more time preparing.

Types of groups:

Nutrition 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.

Support 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.

Health 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 support.

The next several Tips will address group strategies, effective language, leader roles and handling problems.

Additional resources:

Facilitated group discussion:

• “How to make nutrition education more meaningful through facilitated group discussions,” R. Abusabha, et al.; J Am Diet Assoc. 1999:99:72-76.
• “Facilitated Group Discussion” training module, Arizona Department of Health
• The WIC Parent Connections Video

Cognitive Behavior groups:

• LIFESTEPS Weight Management Program; 
• The LEARN Program for Weight Management, Kelly Brownell, Ph.D.

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Tip #85  A Random Collection of Strategies for Groups  

Problems cannot be solved at the same level
 of awareness that created them.
Albert Einstein

A good listener is not only popular everywhere,
but after a while he gets to know something.
            Wilson Mizner

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 most useful.

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: 

Imagine a 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.

Collaboration (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.

Matching 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 shared.

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 them.

Handouts (Tip #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 expertise. 

Behavioral 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.

Ambivalence 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 same.

Confidence 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?” 

Grieving 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 support her.”

Taking care with the end of group meetings (also see Tip #21, available in the Practice 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).

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Tip #86  Attending to Language in Groups    

If I could just find the right words… 
With the right words everything could change.
Barack Obama

For me, words are a form of action, 
capable of influencing change. 
Ingrid Bengis 

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. 

• A nonjudgmental, 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?”

Affirming (Tip #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.

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Tip #87  Problems 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.

Julie Andrews

Behind every difficult person or situation is
a blessing just waiting to be revealed.

Cheryl Richardson

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:

• Time, attendance and assignment expectations
• Confidentiality rules
• Respect and acceptance of everyone

Confidentiality: 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)

Cultural, 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.

Meeting individual 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.  This also reminds the others in the group that they may not get all their needs met through the group.

Getting 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 Topic, (Practice 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 affirmation (Tip #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 keep coming.

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. 

Retaining 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.”

Correcting misconceptions 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:

1. Affirm 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.”
2. Ask 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 more.
3. If 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 that now?”
4. Offer 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.

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Tip #88 Our Role in Groups

Leadership is getting someone to do
what they don't want to do,
to achieve what they want to achieve.
Tom Landry

A facilitator’s job is to support
everyone to do their best thinking.
Sam Kaner

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 roles:

• Teacher of facts/provider of information
• Facilitator of problem-solving
• Shepherd to guide and structure the sessions
• Corrector of misinformation
• Role model for respect and acceptance in sessions

Staying client-centered 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 also 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.

• Food 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 leader.
• Cheerleader: 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.
• Debater: 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.)
• Stand-up 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 client-centered.
• Role 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 make.

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 leader personal 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 questions.

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 include:

• Focusing on the topics that the members bring up (Tip #15, Practice Workbook, Vol. 1)

• Affirming (Tip #63)

• Reflecting (Tip #6, (Practice Workbook, Vol. 1)

• Inviting quiet members to participate (Tip #87)

• Encouraging acceptance of everyone (Tip #87)

• Correcting misconceptions (Tip #87) 

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 yourself.

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 growth.

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Tip # 89 Phone Counseling

For me, words are a form of action,
capable of influencing change. 
Ingrid Bengis
 
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 sessions. 

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 area. 

• 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 for coping: 

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 services. 

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 phone?” 

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 direction (Practice 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 behavior change. 

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 you?” 

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.

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Tip #90  Curiosity

The cure for boredom is curiosity.
There is no cure for curiosity.
 Ellen Parr

Replacing judgment with curiosity
 is a key element in becoming unstuck.

Francie White

Curiosity is…

• a state in which you want to learn more about something
• an emotion related to inquisitive behavior 
• the tendency to ask questions, investigate or explore
• the 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 feeling overwhelmed.  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).

Fear 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 stuck.  Often 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)

For example:

• “Let’s remain curious about that…”

• “Imagine with me...”

• “Hmm, that makes me curious about…” 

• “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 (in Practice 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.

Cautions:

Change 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?”

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