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:
2010 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
91 Do Nothing
Tip # 92 Door Knob Questions
Tip # 93 Addressing Irrational
Tip # 94 Counseling Family and
Tip # 95 The Power of
Tip # 96 Developing
Tip # 97 Shame and Guilt
Tip # 98 Making Referrals
Tip # 99 Feeling Overwhelmed
Tip # 100 Structuring Sessions
Tip # 101 Sustain Talk (11/1/10)
Tip # 102 The Very Beginning (12/1/10)
Sometimes the most urgent thing
you can do is take a complete rest.
No one has a finer command of language
person who keeps his mouth shut.
Doing nothing is not easy.
Righting Reflex (Tip
#65) compels us to fix, or
“right,” anything we see that does not look
often feels uncomfortable.
may feel inadequate if you don’t fill up every
minute of a session with useful information.
There are times in individual
counseling and in groups when stepping back and doing
nothing is of value. For example:
you ask an open-ended question, the client needs
time to come up with a response. That’s your cue
to do nothing and wait.
client may express discomfort, sadness or
ambivalence about what to do. When you jump to
“fix it” by trying to cheer up the client or
tell him what to do, you model the process of
avoiding all discomfort. You can choose instead to
model just sitting with uncomfortable feelings. All
you have to do is reflect. (Tip #6, available in the
Workbook, Vol 1)
Here is where your “doing nothing” is
more than nothing.
Your presence as the client works through a
decision-making process is valuable itself.
You don’t need to “do” anything else
besides reflect back what you hear and ask
open-ended questions. It’s not your job to fix it.
See Tip #5, available in the Practice
Workbook, Vol 1, for more on handling clients’
feel burned out. This likely means you have been
doing too much. Doing some “nothing” is a great
idea. Take a break, stare off into space, take a
walk, take a day off or a vacation.
you find yourself working harder than your client.
This indicates that you are encountering resistance.
Continuing to work so hard just increases the
client’s resistance. Stop and take a deep breath.
For more on how to handle resistance, see Tip #9,
available in the Practice
Workbook, Vol 1.
When it’s hard to do/say nothing,
what do you say? If silence is not appropriate,
you could first buy yourself some time: “Let me think
about that for a moment.” Then you could slowly (Tip
#26, Slowing Down, in Practice
Workbook, Vol. 2) reflect back what you have just heard
and what you know to be true. “So you are asking me to
tell you what to eat at the party. Could we take a
moment first to review what you have learned so far
about what works for you?”
By just summarizing, you resist the urge to fix
the problem. Often something useful happens when you do
There is one more situation where
doing nothing is extremely productive. Incorporating new
information or a new skill works best when the brain has
time to do it. When you have attended a
continuing-education program or are working to learn
something new, give yourself some downtime to let it
settle in. For example, if you are reading one of my
Practice Workbooks, take one Tip at a time. Let it
jiggle around in your thoughts when you are doing little
else (such as driving or going for a walk or run).
to list of Tips
Time is the coin of your life.
It is the only coin you have,
and only you can determine how it will be spent.
Be careful lest you let other people spend it for you.
Feeling inadequate means you are inadequate
at what you are focused on.
You are ending a session, and the client
asks “just one more question.” It may be an
important question that deserves a thoughtful response.
You feel forced to answer in a rushed manner. It is
common to feel annoyed that the client is not organized
enough to ask important questions earlier.
The best way to address these
“doorknob questions” is to prevent them with
careful agenda-setting earlier in the session.
This can be done on the phone when the
appointment is scheduled as well as at the beginning of
the time together. For example, whether you or someone
else sets up the appointment, at a minimum the client is
asked for the primary reason for the consultation. For
follow-up sessions, refer to your notes about what you
and the client agreed to cover this time.
As the session begins, bring up the
topic you understand is most important and also ask the
client what she hopes to accomplish today. Summarize
what you have heard and ask if there is anything else.
This may elicit the miscellaneous questions early so you
can take them into account. When the client assures you
that you have heard all of what she hopes for,
prioritize and agree on what you will work on today. For
example, “So you came today wanting to begin a
weight-loss plan. You have questions about prepared
foods and how to read labels. The question you most want
answered right away is about the cleanse plan your
friend used. I would be glad to give you my opinion
about that and then we will see how much time we have to
begin with your other concerns.” For more ideas on
this agenda-setting process, see Tip #4, Asking Your
Client for Ideas and Direction,
available in the Practice
Workbook, Vol 1..
When you know that it will be
impossible to answer all of the client’s questions
in one session, mention this early. For example, “I
hear that you were not surprised by the doctor saying
you are pre-diabetic since it runs in your family and
your main concern today is to learn what the most
important changes you can make are. You also have lots
of questions about eating out. I know we can get to the
general changes that will be most powerful in keeping
your blood sugar down. We can begin to talk about eating
out, but I know we will only get so far with that and
need to continue that at another visit or I can point
you to some resources online.” This kind of preamble
sets you up for respectfully winding up before the
client has all her questions answered.
No matter how carefully you set the
agenda and prioritize, some clients will still ask
doorknob questions. It is difficult to handle this
situation because you and the client are in different
are winding up the session, and the client is still
engaged in getting needs met. When you answer the
question, you shift back into the session with the
client and have to work to wind up again. If instead you
acknowledge the question while staying in wrap-up mode,
this allows a smoother transition to ending. By doing
this, you are asking the client to accept
disappointment for now. (See Tips #58,
Grief in Nutrition Counseling, and #21, Time Boundaries,
available in the Practice
Workbook, Vol 1.) Making this explicit may help.
For example, “You wonder which canned and frozen
products are OK. I wish we had time to cover everything
today. It is disappointing that our time is up. That is
an important question, and I want to make sure we have
adequate time to address it.” Finally, schedule
another time to address the topic: “When we meet next
month, let’s start with that.”
If an ongoing client asks doorknob
questions almost every time, it will be useful to address
the issue. There are many possible reasons for this
pattern. Here are some:
client may find it uncomfortable to end this
positive contact with you. A simple empathetic
reflection is in order here.
topic may be difficult or scary, and the
client is hoping you don’t have time to address it
fully. Acknowledge the topic and either suggest
discussing it with a more appropriate person
(therapist, pastor, doctor) or bring it up yourself
at the beginning of the next session.
client may have difficulty directing attention consistently
and therefore simply forget questions when prompted
at the beginning of the session. If you have an
ongoing relationship with this client, you could
work with him to problem-solve how to direct
attention to the most important topics first.
After the session, you may be left
with an unfinished feeling. You know you did not fully
address the client’s needs today. This is unsettling. Take
a moment to return to neutral for the next client.
This may mean documenting the unaddressed questions or
making a note to address this topic or this pattern next
time. If the client has a therapist, bring up the
pattern and ask for ideas on how to address it. A deep,
sighing breath may allow you to let go of your
to list of Tips
#93 Addressing Irrational Beliefs
A good listener is not only popular everywhere,
but after a while he gets to know something.
Reacting is an emotional reflex.
Response requires thought.
Gail Pursell Elliott
Clients express irrational or wrong beliefs about
their health or the role of food in treating their
condition. You may hear, “I don’t have diabetes.
My doctor just says that my sugar is a little
high.” Or “I’m not going to breastfeed because
I have small breasts and won’t have enough milk.”
Or “I’m fine at this weight. I’m sure that my
period will come back soon.”
These statements may startle
you, and you may be tempted to argue or to discount what the client has said.
This approach will likely bring up resistance. The
client will either shut down and stop listening or
argue more strongly for her position. Believe your
client’s perspective/beliefs/feelings, even if you
can’t understand them.
Here is a process that makes it
most likely that your client will hear your side and
what you have heard in a straightforward manner.
For example: “Your doctor is concerned that your
blood sugar is high.” “Your reason for not
choosing breastfeeding is concern that you will
not make enough milk for your baby.” “You feel
just fine at this weight and believe that your
period will come back even if you don’t gain any
permission to talk about the topic. “Would
you be willing to discuss this for a few minutes
and hear some information I have about blood
sugar… or breast size and milk production… or
body composition and regular periods?” Or “I
have some information about that. Would you be
interested?” Depending on the circumstances, you
might add language such as, “Of course, it’s
up to you what you choose to do.”
a few facts in a neutral manner without
arguing or pushing your point of view. For more
ideas on neutral wording, see Tip
#59. In these
situations in which
you are providing information that
conflicts with your client’s beliefs, it may be
useful to use charts with normal and dangerous
ranges. For example, you could show where your
client’s recent blood sugars or hemoglobin A1C
fall on a chart and list some of the complications
that occur when blood sugar stays in that range.
for a response and really listen.
you hear any change talk (Tip
#69), reflect it and offer to provide any
other information or support.
This process is based
on the way people naturally take in new
information and consider accepting it. By presenting
it this way, rather than through argument, you make
it more likely that the client will hear you and
truly consider accepting your point of view.
this approach is not enough. Cognitive
distortions may have developed as a defense against
uncomfortable emotions, and the client will not
easily let them go. This is the case with eating
example, a client is acting on irrational beliefs
even though she can say to you that she doesn’t
believe them. For example, “I am too scared to have
salad dressing. It’s made of fat and will make me
fat. I know that’s not really true, but I am still
too scared.” You will not be able to fully address
this in nutrition counseling. A referral for therapy
is necessary. You will still have a role in
respectfully providing correct thinking on an ongoing
basis. These clients may need you to provide this
kind of “reality check” over and over for quite a
Some dietitians help the
therapist on the team by providing some of the
cognitive therapy to address the irrational beliefs.
This process is described in detail in
If you do work with a client in this way, make sure
you share this with the therapist.
Taking care of ourselves:
These clients are extremely
frustrating. Our profession is evidence-based, and we
know what science tells us is true. Why won’t the
client just listen and take our word for it? It’s
easy to discount the client as being in denial about
her condition. We may even feel disrespected as a
professional. The client may indeed be in denial and
not ready to hear the facts. It’s
not about you, and taking it personally will only
make it more likely that you will argue ineffectively
with the client. If you find yourself often upset by
these types of clients, seek supervision.
Stellefson. Winning the War Within: Nutrition
Therapy for Clients with Eating Disorders, 2nd
to list of Tips
#94 Counseling Family and Friends
Feeling hopeless and
being hopeless are
two different things.
Remember that not getting what you want
a wonderful stroke of luck.
The Dalai Lama
Over and over I hear:
should I do when family members or friends ask for
want to start a practice and figure I’ll start by
cousin eats too much. How can I talk with her about
How best to approach these situations? It can be useful
to remember that if you choose to provide nutrition
counseling, whether formally or informally, you will
then be in a “dual relationship” with this person. I
wrote about such relationships in Tip #13 (available in
Workbook, Vol 1). I will summarize the important
points here and provide more guidance on handling these
Let’s use the example of taking
on the role of nutrition counselor for your mother. The
relationship you had will be changed and may be harmed,
and the counseling relationship will be less effective
than if she had met with another dietitian. It may be
difficult for you to shift back into the daughter role.
You may find yourself pointing out her poor food choices
at a family gathering. As you discuss her diet with her,
you will find it difficult to maintain a professional
demeanor and may not be able to bring up tough issues
effectively. On your mother’s side, she will not have
the privacy she would if she met with someone else and
therefore might hold back important details. These are
just some of the issues that may come up.
I hear a clear trend in my
workshops and on e-mail chats. As dietitians have more
years in practice, they are less apt to counsel family
and friends. We learn from experience that it just
doesn’t work well and we become more comfortable
Over and over I hear from new
dietitians that they plan to begin their practice with
family and friends. It does seem easy to begin with a
ready supply of clients among acquaintances. But there
are several pitfalls in addition to the ones mentioned
above. It takes considerable experience and skill to
successfully navigate a dual relationship. Most
dietitians beginning a practice do not have much
experience and are understandably focused on the content
of the sessions. It
takes months or years of experience to begin to be able
to focus on process. This focus on process is a
necessary element of handling a successful dual
relationship. Another reason to begin with strangers has
to do with developing a professional style. With friends
it is difficult to use professional language, to talk
about the fee, to assert your professional opinion and
other aspects of taking on the role of a competent
professional. As an example, think of the awkward shift
it would take to assert your professional opinion to
your grandmother, who still thinks of you as her “cute
Some ideas for responding when
people close to you ask you to counsel them: “I am so
glad you have decided to work on your eating/health. I
have found that it gets too confusing to be your
dietitian and also your friend/niece. I’d rather
remain just your friend/loving niece. I know a great
dietitian at the hospital. She is an expert in
diabetes/weight management/oncology. Here is how to
Sometimes the setting is more
informal. Where do you draw the line when a friend asks
a simple question about the latest fad diet or your aunt
with diabetes asks if it is OK to order the French
of us take the position that we are “off duty” and
just don’t answer. One of my colleagues says, “Oh, I
left my dietitian hat at the hospital.” If this seems
too extreme, you could clarify the narrow question,
answer it and then change the subject. It may be useful
to review the format for giving advice in Tip
It can be painful to watch loved
ones eating in ways that you know jeopardizes their
their dietitian is not the solution. As with any other
behavior that concerns you, the most appropriate
response is a clear and respectful expression of concern
followed by offering resources and then backing off. Tip
#48, Assertiveness (available in Practice
Workbook, Vol. 2), has some useful language.
In summary, refer!
Nutrition is a common concern, and
those around us naturally turn to us for advice. We want
to intervene when we notice the nutrition mistakes of
those dear to us. Even if you are the very best
nutrition counselor there is, you are not the best one
for your friends and family members. The best one is a
colleague whom you have faith in. Since you know your
friend or family member well, you can carefully choose
whom to refer to based on personality and specific
to list of Tips
Power of Reflecting
You can’t fake
Communication is never perfect. We guess our
client’s meaning all the time, and this is normal
in human interaction. By reflecting what we hear, we
take more care with the communication and at the same
time provide a powerful boost to the client. This
essential process of reflective listening is also called
mirroring or just reflecting.
Reflecting involves listening carefully for what
sounds important and reflecting it back in your
own words. You are making a guess about what you believe
the person means and reflecting it back as a statement.
It’s so simple and yet so powerful. In Tip #6,
Mirroring (available in the Practice
Workbook, Vol 1), I discuss the functions of
reflecting and give examples. Here we explore types of
reflections and provide more detail on how to make them
Brain research shows us that we
all naturally mirror in our brains when in the
presence of other people who are doing or experiencing
something familiar to us.
In order for this to be useful to the client it
needs to happen out loud. Humans naturally mirror on
lots of levels. You can train yourself to add the ones
you don’t do already.
You can reflect:
Body language: We tend to
mirror the body language of people we are talking with.
You can do this deliberately to encourage rapport.
Tone of voice: This also
supports rapport and goes further to tell the client you
are attending to her.
A phrase: You can highlight
important statements you hear by reflecting just the
important words. “..care about your kids...”
“…this annoying condition...”
One word: You can even do it
with one key word: “kidneys,” “tired.”
An emotion: When reflecting
emotions, it is best to err on the side of understating
the intensity of the emotion. For example, a client
sounds angry. If you reflect strongly, “You were very
angry at him for taking away your plate,” you will
likely get an argument from the client. When you
reflect, “You were annoyed with him for taking away
your plate,” the client is more apt to simply
elaborate and continue.
A whole concept or process:
“You find that when you get home from work and
didn’t have an afternoon snack, you are more apt to
eat something unhealthy at dinner.”
Types of reflections:
Simple: Here you are simply choosing to
repeat back what the client has said, though maybe
in slightly different words.
reflect both sides of the client’s ambivalence.
Reflection with a reframe:
word choice, you offer to reframe how the client is
approaching a situation. (See Tip #10, Reframing, available in the Practice
Workbook, Vol 1)
Reflection with a twist:
You can choose to reflect what has been said and
then continue the thought just a bit.
Summary: You reflect
back a whole paragraph of what you have been
hearing. (See Tip
Here is an example. The client has said these statements
in one section of a session: “I love walking.” “I
know it would be good for my blood pressure.” “I
don’t have enough time.” “I prefer to do it with
Simple reflections: “You like walking.” Or
“You know walking would help bring your blood pressure
Double-sided: “On the one hand you like walking
and know it’s good for you and on the other, you
don’t like doing it alone and have trouble finding
time for it.”
Reframe: “You’re a walker.”
Twist: “You like walking and haven’t yet
found a way to fit it in.” Or “You know walking
would be a good idea and are considering ways to make it
Summary: “So if I understand you so far, you
know that walking more would be a good idea for your
blood pressure and you have always liked walking with
others. At this point you’re thinking about how to
work it back into your life.”
Powerful reflections are statements,
not questions. It is tempting to turn a reflection
into a question by raising the inflection at the end.
This weakens it and can turn it into a closed question.
For example: Notice the difference between “You are an
all-or-nothing kind of person?” And “You are an
all-or-nothing kind of person.”
A question demands an answer, and
this will interrupt the client’s flow. The rare times
when your reflection statement is significantly off, the
client will correct you. So there is no need to turn
your reflections into questions.
When to reflect:
After an open-ended question, a reflection
keeps the exploration process going that you started
with your question.
This encourages the client to do more work in
the session. (See Tip
#60, Open and Closed Questions)
When the client is thinking
People talk about changing before they do it,
and the more they talk about it in specific ways the
more apt they are to change. So when you hear this
“change talk,” reflect it. This puts a spotlight
on it and elicits more of it. The client will hear
her own motivations and plans at least twice. (More
on Change Talk in Tip
Part of your job is to help
clients see that they are ambivalent, and you do
that by reflecting it when you hear ambivalence.
Then you can offer to explore it further with
When you hear a strong
feeling, you might choose to reflect it: If the
feeling is directly related to food behaviors, it
may be appropriate to simply reflect it and explore
a bit more. If, on the other hand, the emotion seems
tangential and getting in the way of the session,
you want the client to contain it and bring it up
elsewhere. In this case, you might instead say,
“This sounds important. Do you have someone to
discuss this with?” (See Tip # 5, How to Respond
to Your Client's Strong Feelings,
available in the Practice
Workbook, Vol 1)
When you sense resistance:
For example, you hear “yes, buts” and
complaints. The most effective thing to do with
resistance is to roll with it. You do this by
reflecting what you hear. For example, “You
don’t like spinach” or “Cooking isn’t fun
for you” or “You don’t like your doctor’s
As you finish discussing one
topic and at the end of the session, offer a
summary that reflects what you have heard from the
client matters to her and what she plans to do.
We all naturally mirror in our brains.
There is great variability in the extent to which
we do it out loud. Observe
what types of visible/verbal reflecting you already do
naturally and well. Find ways to reflect more
to list of Tips
Tip # 96 Developing
If you’re doing something that does not make
look deeper: It makes sense.
When we are no longer able to change a situation,
we are challenged to change ourselves.
Does this sound familiar? A client tells you she really
wants to lose weight, and in spite of all your good
advice, she does not change the way she is eating. She
seems to have a strong desire for the outcome (weight
loss) and may even see herself as an active and slimmer
person, yet her behaviors
are at odds with her goal. When you encounter this
situation, it may be tempting to educate more or try to
cheerlead the client to change. This will likely elicit
resistance and arguments against change.
So what can
you do? Let’s look at how
people naturally make changes. It begins when the
person notices a discrepancy between the current
situation and what is desired. A simple example: A young
person beginning a career wants to be seen in her new
job as a competent professional and realizes that her
wardrobe does not support this image. This motivates her
to shop for professional clothing, and she may even ask
for feedback on her choices from mentors. An important
step here is that she perceives the discrepancy.
If she wants to be seen as a professional but does not
perceive a connection between that desired goal and her
clothing, she will not be motivated to look for
Another woman may not care about being seen as a
professional. Even if she knows that clothing
contributes to this image, she will not be motivated to
enhance her wardrobe. If, however, she sees a connection
between clothing and landing her desired job, this will
cause the discrepancy that will motivate action.
So our clients are
motivated when they are aware of a discrepancy
between certain of their values, sense of self, or
desires and the current situation or what they are doing
Some examples of discrepancies
in our work:
desire to be healthy for the sake of a spouse and
high blood sugars that will lead to complications.
self-perception as a cooperative patient and very
few food records filled out.
belief that God wants him to take good care of his
body and a high waist-to-hip ratio.
self-image as a good parent and rarely providing a
calm family meal.
These discrepancies may be obvious
to us. Our
client may not yet see the discrepancy clearly enough to
motivate change. In some cases what we see as a
discrepancy is not one to the client because we imagine
that something is important to the client and it simply
isn’t. In order for the discrepancy to be motivating
it must be clear
and meaningful to the person. Sometimes we don’t
know precisely what the discrepancy is. We just know
that there must be at least one since the status quo
does not jibe with expressed desires. We may not know
what values or desires are most motivating to this
person or which aspect of the status quo will appear
most out of line with these goals. We can proceed to
develop the discrepancy with the client whether we can
see it or not.
To help a client see a discrepancy,
ask guiding open-ended questions (Tip
# 60). The goal is to point
the client’s attention toward any discrepancy and
see it more clearly. Doing this effectively takes skills
and practice. Careful research has shown the stance and
techniques we can use that will most likely mobilize the
client’s own motivation toward change.
What not to do:
It may be tempting to confront
the client, especially when you can see the
discrepancy between what is voiced as reasons for change
and current behavior. These questions will bring up
resistance rather than exploration:
you keep eating this way, you will end up on
you see that all these processed foods contribute to
your high blood pressure?”
you really believe that your weight is not affecting
These bring up defensiveness and
will elicit reasons to not change. Voicing the reasons
to not change makes change less likely. It is easy to
get into this type of arguing. If you sometimes find
yourself doing it, see Tip
#65, The Righting Reflex, for some useful reminders.
Three techniques to use over and
values and desired goals with open-ended questions.
me what concerns you most about your blood
do you see yourself getting from weight loss?”
do you see yourself two years from now?”
kind of person (wife, parent or citizen) do you see
you hear, especially values. Your job is to nurture the
environment that will build a discrepancy in the client
and eventually allow the client to resolve it.
Expressing empathy by reflecting creates this
care a lot about your children and really want to be
around for them.”
like to see yourself as a person who takes good care
a mostly healthy eater is how you see yourself in
believe in the local foods movement for the sake of
the environment and because you believe that mostly
eating local will mean you are eating healthier.”
seen as a cooperative patient is one of your
what you are hearing.
“So in spite of your struggles you know
you are a pretty good parent. You like learning about
what helps children grow up to be healthy and you know
the importance of fruits and vegetables. Recently days
have gone by when you haven’t offered any of them to
You may need to rotate
through these steps many times.
When some ambivalence appears, as in the above
example, more open-ended questions guide the client
toward seeing a discrepancy.
does all this look to you?”
kind of eaters would you like your kids to be when
they grow up?”
me how you see your life five years from now,
assuming you keep doing pretty much what you are
Helping a client see a discrepancy
usually leads her to awareness of ambivalence to change.
This realization of ambivalence is an important step.
We can highlight it by reflecting it back. When
ambivalence is worked through, real change happens. (See
As you explore discrepancy with a
client, you will notice
change talk. Take the opportunity to reflect all
that you hear. See Tip
#69 for more on change talk.
Many of our clients focus
attention on the negative behaviors they know should
change. This has the effect of increasing resistance and
keeping them stuck. Attention on values (or ideal self)
pulls clients toward change toward change, and
defensiveness decreases. The focus moves away from
negative behaviors and toward positive ones. Working to
line up behavior with values is easier than attempting
to stop behaviors we call “bad.”
This process can also guide us when
we see a client struggling with incongruity between short-
and long-term goals (i.e., pleasure or comfort of
food vs. health and/or weight). Our
open-ended questions and reflections acknowledge these
values and desires. We can support the client to find
other ways to meet the short-term desire. This is much
easier to do once that desire has been clarified and the
client has voiced it. For example, when a client
acknowledges that food provides much-needed comfort in
tough moments, she can search for other ways to find
This type of questioning can open
up a broader discussion that at first seems inappropriate in nutrition
counseling. Sometimes we elicit values, religious
beliefs or the client’s desired perception of herself.
We can become comfortable with reflecting these and
tying them back to food behaviors.
What our clients choose to do in
the face of a discrepancy is always up to them. Our job
is simply to help them see it more clearly.
to list of Tips
Tip # 97 Shame and Guilt
Humility is wisdom.
Shame is not.
Positive guilt occurs when we begin to
break rules that need to be broken.
Guilt and shame often arise in
nutrition counseling, so it’s useful to understand
is what a person feels when he believes he has done
something wrong (or neglected to do something) and
thereby harmed someone or violated a moral code. The
focus is on the action. “I did something
wrong/immoral/bad.” The person may experience remorse
and feel the need to make up for it somehow. At times,
guilt is based on an erroneous belief. Examples you may
client who experiences guilt at having one bite of a
cookie based on the belief that this will cause a
blood sugar spike.
client arrives for a session and says, “I was bad.
I ate some foods not on your food plan.” The
client has internalized a rigid standard around
food. Then when she can’t adhere, she feels guilt.
This guilt may even cause her to not keep a
guilt over eating “bad” foods or eating too much
may lead to a client’s attempt
to “punish” herself with unrealistic restricting
or excessive exercising. This strategy for coping
with feelings of guilt perpetuates eating problems.
shame, the focus is on the self. “I am a
bad/unworthy person.” Shame feels like intense
embarrassment. Those experiencing shame look down, may
blush and often have difficulty thinking clearly or
speaking. It is experienced as a strong desire to
disappear. Shame is a particularly intense emotion.
Examples you may see:
client has great difficulty telling you about a
particular eating behavior such as purging. It may
be hard to distinguish here between guilt and shame.
Downcast eyes and focus on her self-worth and what
you will think of her are clues it is shame.
over excess weight or over a chronic condition such
as diabetes may keep a person from engaging in life.
who have difficulty eating in public are likely
clients avoid weighing themselves because seeing the
number causes them to feel shame.
Those who experienced childhood
abuse or neglect generally experience more shame, and it
is easily triggered. This
“false” or “toxic” shame results from chronic
inaccurate and negative mirroring.
Over the centuries, shame campaigns
have been used in an effort to control behavior. The
“scarlet letter” in puritan times is one example.
Today, TV shows, magazines, and comments by medical
professionals, family members and even strangers can be
shaming. They are often directed at body weight. The
intention may be to change behavior. However, shame is
not an effective motivator of behavior change. Shame
leads to inaction, depression and a repeated drive to
feel better, which may include turning to bingeing,
restricting or other maladaptive behaviors. For some,
guilt experienced over and over also contributes to
What you can do to address guilt
- Carefully tease out the beliefs about food and
body that underlie the shame and/or guilt. When you
encounter erroneous beliefs, provide a different
perspective. Sometimes I refer to this part of my
job as reality-checking. “Oh, so you assume you
did something wrong when you chose to eat the french
fries? Would you like my perspective based on
research and other clients’ experiences?” (See Tip
#59, A Format for Providing Advice.)
- When you see signs of shame, pause. Then after a
moment, gently get the client’s attention. This
may be a good time to use the client’s name. When
the client appears to have recovered from the shame,
you may choose to offer a reframe. (See Tip #10,
available in the Practice
Workbook, Vol 1)
- Some clients have difficulty talking about
negative behaviors because they believe you will
look down on them or find them disgusting. The
antidote to shame is contact. This means being
“seen” and accepted as a worthy person in spite
of certain behaviors. When a client shares
embarrassing behaviors, it’s best to continue to
look at the client. If she sees that you can look at
her with positive regard, this helps heal the shame.
- Take care when weighing clients. Carefully notice
the response to the number and “reality-check”
when necessary. Shifting to blind weighing helps
some clients let go of a shame relationship with the
- Avoid using words that may shame such as
“obese.” Many people with chronic conditions
find it shaming when professionals refer to them as
a “diabetic” rather than a “person with
diabetes.” Some “you” statements induce shame
or guilt, such as “You shouldn’t drink regular
soda,” “You don’t get enough exercise,” or
“You just shouldn’t go to buffets.” (Also see Tip
#54, Watch Your Language.)
- Avoid talking about “good” and “bad”
foods. This sets up the client for guilt when
invariably he does eat some of the “bad” foods.
Many clients use this language themselves. You can
educate them about the ineffectiveness of this
manner of choosing foods.
- Reframe guilt as regret. Shift from “I am bad
because I ate cake” to “I regret having eaten
the cake because my blood sugar was high afterwards
and I care about my health.” This allows more room
for choice next time.
- Refer for psychotherapy when you see signs of
depression (see Tip #41, in Practice
Workbook, Vol. 2) or when you offer
counter-beliefs to the client’s inaccurate guilt
and/or shame-inducing beliefs and the client seems
unable to absorb them. Clients who isolate
themselves out of shame will likely need therapy to
work through it and reenter life.
Shame and guilt are very
uncomfortable and powerful feelings. Gain skill at
recognizing and responding to them to serve clients
well. This has been only a brief overview.
For more in-depth reading, I recommend:
- Eating Problems, by Carol Bloom et al., 1994, HarperCollins, takes a more complex look at the interplay between shame, guilt and eating.
- Cognitive Behavior Therapy and Eating Disorders, by Christopher G. Fairburn, 2008, Guilford, has practical approaches to addressing irrational beliefs.
special thank you to Linda S. Ber, RD, LDN, CDE, who
helped me tweak this Tip.
to list of Tips
Tip # 98 Making Referrals
I not only use all the brains I have,
but all I can borrow.
I think knowing what you cannot do
is more important than knowing what you can.
We all need at times to refer a
client to a colleague or to an additional health
professional. You may pride yourself on being a
generalist, trained and experienced to work with a wide
range of clients. There are always a few clients who
will be best
served by someone else.
Cues to refer:
client calls for an appointment to your private
practice and gives a complicated story about
puzzling gastrointestinal symptoms. Your experience
with GI conditions is limited and you have a
colleague nearby who works in a medical practice and
sees many such cases.
know enough to advise a client undergoing
chemotherapy for cancer. However, your mother has
just been diagnosed with breast cancer. You are not
sure if you can keep from crying or mentioning your
mother when working with the client. (See Tip #16,
Handling Your Own Feeling, (available in the Practice
Workbook, Vol 1.)
client comes to you for diet guidance for diabetes.
You find out that his physician closed her practice
a few months ago and the client has not begun with a
family brings their teen to you and it is obvious
that she has the beginning of an eating disorder.
They know a therapist whom they used to see for
their son, but would rather just have their daughter
meet with you. She is very interested in nutrition
and has lots of questions.
have decided to limit your practice to diabetes and
weight management. A client calls for a consult on
weight management client is not making any changes
and you suspect depression and/or anxiety. (See Tip
#41, When Your Client Is Depressed, in Practice
Workbook, Vol. 2).
have experience working with families and teens to
develop healthy eating habits. You also work with
clients with eating disorders, including young teens
and their families. You realize that you have
recently been losing patience with the teens. After
discussion with a supervisor, you see that this is
because your own teenager is acting rebellious and
you can’t help but transfer some reactions. For
your own sake as well as your clients’, you choose
to define your practice as not including young teens
until you get beyond that stage in your family’s
ongoing client seems to get off track from healthy
behaviors when anxiety or emotions pop up. You know
of a local stress management class or other resource
that you believe would support your work with this
work in a wellness or weight management setting and
a client comes in with a BMI of 19 who wants to lose
“ten more pounds.”
It looks as if the client has an eating
disorder, but it is tempting to try working with the
client for a while.
A format for referring: This
is just one possible format. It can be useful to have a
format to rely on when you are unsure how to proceed.
what you hear from the patient’s perspective.
“You have a lot of questions and worries about the
best way to eat when doing the chemo.” “Your
focus on food and weight is taking up a lot of your
life and it bothers you that you haven’t had a
period in three months. I hear that you are scared
to eat more.” “You clearly care a lot about your
health. You called me and want help to eat well for
a truth or two. “My expertise is not in the
area of oncology. I have a colleague who has helped
a lot of people in your situation.”
“Your lack of periods is most likely due to
inadequate nutrition. I have found that in this
situation it works well to meet with a dietitian who
specializes in eating disorders.” “Several
of our patients with that same concern have found it
helpful to meet with a counselor.” “Research has
shown that working with a therapist on anxiety
management makes it easier to reach weight
permission to provide a referral or resources.
“Would you like me to give you her name and
number?” “I have names of several therapists who
help people let go of obsessive food and weight
thoughts. Would you like their contact
for a response before giving the referral.
When the referral is for your own
what you share to a minimum and word it from the
client’s perspective. If you are tempted to share your
personal reasons for making the referral, review Tip #1,
Self-Disclosure (in the Practice
Workbook, Vol 1).
is a practice specialty that I don’t work with. I
want you to have the very best dietitian.”
this time I am not taking clients in your
daughter’s age group.”
will be taking some time off from my practice in the
next few months and I want you to have someone you
will be able to see weekly.”
Additional notes about eating
disorders for those who do not treat them:
When you have determined that a
client has an eating disorder and will be best treated
by an experienced team, hold back your nutrition expertise. The sooner you make a referral
to an eating-disorder professional, the better. You
pride yourself on your knowledge and so it may be quite
difficult to refuse to answer detailed nutrition
is one time to fake ignorance to get the client to see
an eating-disorder professional. If the client is not in
treatment yet (and is in denial), trying to treat him in
your setting or even answering simple questions is doing
the client a disservice.
team approach is the standard of care. The team will
include a psychotherapist, dietitian and primary care
provider (ideally with eating-disorder experience). A
psychiatrist and family therapist may also be needed. It
is not unusual for the client to be willing to see only
one at first. For example, she may want to see an RD
because she has lots of food questions, or a
psychiatrist or therapist if she is depressed.
It will then be up to the eating-disorder
professionals to assemble a team. Develop relationships
with eating-disorder professionals nearby to refer to.
Making referrals is a tricky part
of your job. Ask for help and practice, practice,
you suspect that it would be best to refer a client
to someone else but you feel unsure or confused, consult
with a supervisor, colleague or the professional
you may refer to.
you are fortunate enough to know that you will be
seeing a client who needs a referral, review this
Tip and go
over your wording with a colleague. Consider
bringing notes to the session.
a referral doesn’t go very well, go
back and play with an approach and wording that
may have worked better. Practice it in your head or
with a colleague.
you feel guilty about sending a client away, remind
yourself that professionals
find the very best care for their patients.
to list of Tips
Tip #99 Feeling Overwhelmed
Take the first step in faith.
You don’t have to see the whole staircase,
just take the first step.
Martin Luther King Jr.
The way you think about a fact may defeat you before
you ever do anything about it.
You are overcome by the fact because you think you are.
Norman Vincent Peale
Being overwhelmed is a
familiar feeling for most of us. You feel it when there is a lot to do in limited time. You may have multiple projects you are excited about and feel as if you are not making progress with any of them. You often experience it as too much of something (responsibilities, anger, even joy). Your clients may get overwhelmed with the changes they need to make. Or you might notice a client is chronically overwhelmed in several spheres of life, making diet changes more difficult. Staying in a state of feeling overwhelmed is never productive. Feeling inadequate often follows feeling overwhelmed.
Some synonyms are submerged, engulfed, beaten, flooded, swamped, defeated, conquered. Notice the
dual themes of being both vanquished and covered
over. No wonder it’s so hard to do anything in those moments. A Chronic feeling of being overwhelmed leads to depression, and depression makes it more likely the person will feel overwhelmed easily. (See Tip #41, When Your Client Is
Depressed, in Practice
Workbook, Vol. 2)
To get out of feeling overwhelmed:
1. Acknowledge it.
2. Take a moment to breath.
3. Notice that of the things causing the feeling, some are more urgent or important than others.
4. Notice which elements you have control or influence over and which ones you don’t.
5. List some things that can be put off for now, or may not even be necessary.
6. Take deep breaths to help you let go of what you can’t control. Some find prayer useful.
7. Pick one thing to do right now. Doing one thing at a time is calming and is the most effective way to make progress.
A common complaint I hear from nutrition counselors is that they
do not have enough time with each client. This leads to feeling overwhelmed. Acknowledging the time limitations out loud to the client is the first step. When you then negotiate what you will cover, your sense of feeling overwhelmed diminishes. More suggestions are in Tip
#43 (in Practice
Workbook, Vol. 2) When We Have Little Time, and Tip #21, Time Boundaries in
Sessions (in the Practice
Workbook, Vol 1).
You also become overwhelmed when you expect too much of
yourself. Sorting out what you can and cannot do (Tip
#33, in Practice
Workbook, Vol. 2) goes a long way toward calming. When the expectations of others are overwhelming, the sorting out can be more complicated. (See Tip #44 for
strategies, n Practice
Workbook, Vol. 2)
At times in nutrition counseling, you become overwhelmed with your client’s larger problems. It can feel as if you are being asked to do
psychotherapy. It may be useful to review the edges between these two types of counseling and make a referral. (See Tip #31, Nutrition Therapy & Psychotherapy: Where are the Edges?
Workbook, Vol. 2) and Tip
#98, Making Referrals.)
Professional burnout is a consequence of being chronically overwhelmed. Check out Tip #22
(in the Practice
Workbook, Vol 1) for more ideas on avoiding burnout.
Helping your clients who feel overwhelmed:
One of your most important roles is to guide a client in the steps to get out of feeling overwhelmed. When the client complains of being overwhelmed,
reflect it and ask if he would like to address that. “You are overwhelmed right now. Shall we take a look at what you can do?” If the client appears overwhelmed and not aware of it, your reflection brings it forward. “It sounds to me like you are overwhelmed with all your health issues. Might it be useful for us to take a moment to sort them out?”
With the client’s permission, you then ask open-ended questions to support the process of getting out of being overwhelmed. “Let’s take a moment to breathe deeply and become calmer. Now, tell me what you know about the relative importance of each of these health issues.” “Help me see which of these things you can do something about and which you can’t.” “What do we know for sure to be true about this?” (See Tip #50,
Workbook, Vol. 2, for more examples of this line of questioning.)
With this simple guidance, many clients are able to choose a few steps they want to take. You will notice their tone changing toward more confidence. You can then
reflect the change talk (Tip #69) you hear and you are back on track.
Monitor the client’s confidence to make a specific change or changes by asking scaling questions (Tips #42,
Workbook, Vol. 2, and 76). This will keep the client from slipping back into feeling overwhelmed and show her a process to use to make it less likely in the future.
Some clients will need more support to narrow down and pick a limited number of things to do next. “Most people find that focusing on one change at a time works best. Which feels most doable right now?” or “It sounds like listing all these things going on in your life is overwhelming you again. How about another deep breath? Now remind me which things you have some control over.”
Your job is to pace sessions so as to not overwhelm your clients. One way to do this is to carefully assess readiness for change (Tip #7) and to avoid eliciting resistance (Tip
#9). Both are available in the Practice
Workbook, Vol 1.
Some clients struggle with accepting what they cannot change. Tip #12 has ideas on how to
support acceptance (in the Practice
Workbook, Vol 1).
Finally, reframing (Tip #10, in the Practice
Workbook, Vol 1) can shift thinking and loosen up the feeling of being overwhelmed. “It’s just all too much. I can’t do it” can be reframed to “I am someone who wants to do the best I can for my health and right now I can do this one thing.”
to list of Tips
Tip # 100 Structuring
Those who fail to plan, plan to fail.
To simplify complications is
the first essential of success.
George Earle Buckle
I am frequently asked for guidance
on structuring client sessions. Do you just ask what the
client is interested in talking about and then go with
the flow? Or do you follow a careful structure to make
sure you cover everything? I suspect the best
answer lies somewhere in between. If we simply
follow the client, we may neglect to do a thorough
assessment or miss educating on important facts. If we
always follow the same format, we will be inadequately
Excellent templates and algorisms
already exist for nutrition counseling. For example, the
Process (NCP) of the American Dietetic Association
that is the standard of care in the field provides a
comprehensive step-by-step process. As we follow it, we
are assured of doing our job in a professional and
thorough manner. The NCP does not give detailed guidance
on the counseling process (i.e. when we are sitting with
a client or talking on the phone and it is time to
address behavior change.) The NCP does emphasize
throughout the need to remain client-centered and to
form goals with
the client rather than for
the client. Bauer
and Sokolik’s textbook, Basic Nutrition
Counseling: Skill Development (
, 2002), includes a comprehensive format to guide the
counselor through a session.
In the heat of a session, it is not
easy to remember these algorisms. It is well known that
the human mind is capable of holding only five to seven
thoughts at once. As you take in what your client is
saying, it is easy to lose some of what you need to keep
track of. Here I have collected several very
simple formats to keep in the back of your mind
during sessions. Their simplicity may allow you to stay
grounded while fully taking in the client’s
perspective. You may feel most comfortable with one
format and use it exclusively or you may try different
ones and choose the one that works best with particular
clients or circumstances. These formats form the
“meat” of the session and are sandwiched between the
opening and the closing. The opening includes greeting
the client, establishing the purpose of the visit and
asking permission to proceed. The ending includes a
summary and plan for future visits.
importance and confidence to make a change: This
format has the elegance of simplicity and implies a
client-centered process. The central part of the
session would include exploring with the client what
is important to her about health, nutrition and the
eating process. This will mean beginning in a very
open manner and then narrowing down to one or two
specific changes the client agrees are important.
(Tip #20, available in the Practice
Workbook, Vol 1) Once the client agrees that it
is important to her to address the specific changes
(i.e., eating at home more often, testing blood
sugar to get useful feedback or switching from whole
to low-fat milk) it is time to switch to addressing
confidence. (Tip #42, available in the Practice
Workbook, Vol 2) As you are exploring the
client’s confidence to make the important change
or changes, you are also assessing the likelihood
she will succeed and finding out what other
resources she may need. This two-step process is
especially useful with clients who may be in the
early stages of change or whom you don’t know yet.
There is more detail on this process in Tip
#59. You begin by asking what the client already
knows about the topic of this session and what he
needs from you. Then you provide some information or
advice and follow up by asking an open-ended
question to elicit his response. Sometimes the
“providing” part of the format is not advice,
but feedback from you. For example, review his lab
results with him or state what is likely to happen
if he makes no changes or give feedback on the
composition of his current diet. This simple
three-step process can be used many times throughout
a session until it’s time to summarize and end.
This format can be used with any client, but may be
especially appropriate with clients who are clearly
engaged in the change process.
Talk: Maintaining attention on change talk is a
powerful, centering focus for a counselor. At the
beginning of a session, you may hear some change
talk. Carefully reflect what you hear. Use the list
of types of change talk in Tip
#69 to decide which types you have not heard yet
and elicit more with directive, open-ended
questions. When it is time to summarize, you will
have a collection of motivating change talk to offer
back to the client.
in doubt, ask! For example, when a client seems
ready for specific advice and you wonder whether to give
general tips and food ideas or whether to provide menus,
ask. The client knows better than you how she makes
changes best. Keep checking in on your process. Include
the client in the decision-making about where the
session needs to go. Tip #4,
available in the Practice
Workbook, Vol 1, has more examples.
No matter what format you employ, a
summary at the end is essential. Tip
#72 has more detail on summarizing. A skillful
summary includes almost exclusively what the client has
said, not what the professional’s ideal plan would be.
All of these simple formats have
the advantage of being practical
when you have very little time. Even in a clinic
setting, when you are given only a few minutes with a
client, you can focus on one of these formats and then
to list of Tips
Feeling powerless means
you are focused on
something you can’t control.
Drawing on my fine
of the English language,
I said nothing.
Clients tell us where they are in
the process of change.
#69 we looked at change talk, the specific client
language we hear when a client is moving toward change.
We support the change process by reflecting change talk
and by skillfully eliciting more. Just as change talk
can be usefully categorized, its opposite, sustain talk,
Desire: “I don’t want to eat
Ability: “I can’t walk more.”
Reasons: “Eating this won’t
help with my constipation.”
Need: “I don’t need to lose
Commitment: “I’m not going to
keep this food record.”
Taking Steps: “I haven’t done
When we encounter change talk, we
reflect it in order to accentuate it. The best response
to sustain talk is silence. An exception is when you are
hearing only sustain talk. A brief reflection of sustain
talk signals to the client that you are listening and
accept what is true for him. This serves the important
process of engagement. For example, you may notice you
are arguing with the client. All the statements you hear
are pointing to not changing. Very briefly reflecting
some of what you hear can end the argument and regain
rapport. Then switch to open-ended questions (Tip
#60) that will elicit change talk.
Of course, it’s wise to avoid
anything that will evoke sustain talk.
Examples: “Why don’t you eat fruit?”
“Could you walk after work?” “Why didn’t you
write in your food record?” “Why don’t you want to
lose weight?” This style of wording can be tricky to
avoid. We ask these questions in an effort to move the
change process along. Unfortunately, they are more
likely to elicit sustain talk and stall the flow toward
the questions that elicit change talk in Tip
When using summaries to begin a
transition or to end a session (Tip
#72), mention just a bit of sustain talk and as
carefully as possible include all the change talk you
heard. Strike a balance between ignoring the sustain
talk and acknowledging it. This may mean using
minimizing language. For example: “You don’t
particularly like vegetables.” “You haven’t yet
begun to exercise.” “You are unsure about whether
eating more fiber will help your constipation.”
For those who use the decisional
balance concept to work with ambivalence to change, it
is common to explore each of the four squares. (Pros and
cons of changing, pros and cons of staying the same.)
This way of looking at decision-making is very useful
when it does not matter what the person chooses to do.
For example, choosing which type of equally beneficial
exercise the client will pursue. However, for a food
behavior change such as eating more fruits and veggies,
there is an assumed “right” choice. The client came
to you with a goal and this change is tied to that goal.
In these discussions, it is counterproductive to
deliberately evoke sustain talk.
A final note: Resistance and
sustain talk are not exactly the same thing. Sustain
talk is about the behavior, and resistance is about the
relationship between you and the client. For example,
take the statement “I won’t drink skim milk and you
can’t make me.” The first part is sustain talk. The
second part is resistance. Understanding this
distinction may help you decide which way to go when you
encounter negative statements. If you are hearing
resistance, roll with it. “Indeed, I can’t make you
do anything. It is your choice.” In
response to sustain talk, it will be more effective to
ask questions likely to elicit change talk. “Tell me
more about benefits you would get from eating lower fat
to list of Tips
The Very Beginning
Research shows that the most important factor
in a successful outcome for therapy
is a positive therapeutic relationship …
as determined by the client.
A journey of a thousand miles
begins with a single step.
What we do and say in the first moments of an
initial session have a profound impact on the whole
treatment. Think of times when you were a client and the
beginning did not go well. The professional may have
appeared distracted or focused on the chart. You may
have felt attacked or lectured. The professional may
have been rushed from the initial moments. How we
interact with clients at the very beginning matters.
Here are some of the questions
being answered by the client in those first few
this person care about me or just her paycheck?
it be safe enough here to be honest about what I
I have any input and choice in this process?
We know that positive change is
most apt to happen in a supportive relationship.
Engagement is the formation phase of that
powerful bond. It sets the tone for a collaborative,
client-centered process. When the bond is not formed or
is lost, it is difficult to reengage.
How to engage quickly and
you begin with some small talk, refer to the
client’s experience rather than yours. For
example, ask about the traffic he encountered or
whether it has stopped raining yet. Respond to the
client’s small talk with simple reflections (Tip
#6). Even when what is being said is mundane,
respond to it.
your body language and eyes to focus on the
client. Face the client at the beginning, even
if you will need to turn toward your computer later.
Keep your eyes on the client rather than your notes.
yourself very briefly, maintaining eye contact.
Resist adding detail about your credentials or role
you introduce how you see the first session going, include
the client’s point of view and ask permission.
For example, “I need to find out about your
medical history and eating habits today. There will
also be plenty of time for you to tell me your
perspective and what you want out of this. How does
that sound to you?”
with open questions as early as possible (Tip
#60): For example, “What brought you here?”
“What do you hope to get?” “Tell me what your
doctor has told you.”
your closed questions for the first few minutes
and circle back to them later.
with any resistance you hear. When you ignore
statements such as “My wife made me come,” you
reduce engagement. Instead, simply reflect it.
“This wasn’t your idea.”
The engagement stage may be
brief, lasting only a minute. Clients who have
experienced negative relationships with nutrition or
medical professionals will likely need longer.
It may take several minutes or even most of an
How do you know the client is
engaged and you can move forward?
will be reasonably good eye contact.
may notice a shift in body language toward
client will share some of what matters and may begin
Attend to engagement at the
beginning of each session even if the client is long
term. Most people take a few moments to feel connected
again. Wait to jump into the work until you sense the
to list of Tips