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Counseling Tips for Nutrition Therapists Series
2010 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:
                  © 2010 Molly Kellogg, RD, LCSW
                  www.mollykellogg.com
2. Don't edit the copy at all without checking with me.

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

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

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Tip # 91   Do Nothing  (1/1/10)
Tip # 92   Door Knob Questions (2/1/10)
Tip # 93   Addressing Irrational Beliefs (3/1/10)
Tip # 94   Counseling Family and Friends (4/1/10)
Tip # 95   The Power of Reflecting (5/1/10)
Tip # 96   Developing Discrepancy (6/1/10)
Tip # 97   Shame and Guilt (7/1/10)
Tip # 98   Making Referrals (8/1/10)
Tip # 99   Feeling Overwhelmed (9/1/10)

Tip #91  Do Nothing

Sometimes the most urgent thing
you can do is take a complete rest.
Ashleigh Brilliant

No one has a finer command of language
 than the person who keeps his mouth shut.
Sam Rayburn

Doing nothing is not easy.

• The Righting Reflex (Tip #65) compels us to fix, or “right,” anything we see that does not look right.
• Silence often feels uncomfortable.
• You 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:

• After 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.
• A 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 Practice 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’ strong feelings.
• You 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.
• Sometimes 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 this.

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).

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Tip #92 Doorknob Questions

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.
Carl Sandberg

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 phases.  You 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:

• The client may find it uncomfortable to end this positive contact with you. A simple empathetic reflection is in order here.
• The 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.
• The 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 disappointment.

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Tip #93 Addressing Irrational Beliefs

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

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 consider it:

• Reflect 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 weight.”
• Ask 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.”
• Provide 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.
• Ask for a response and really listen.
• If 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.

Sometimes 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 disorders.  For 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 while.

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 Fairburn¹ and Myers². 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.

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Tip #94 Counseling Family and Friends

Feeling hopeless and
being hopeless are
two different things. 
Thom Rutledge

Remember that not getting what you want
 is sometimes a wonderful stroke of luck.
The Dalai Lama

Over and over I hear:

• “What should I do when family members or friends ask for nutrition advice?”
• “I want to start a practice and figure I’ll start by counseling friends.”
• “My cousin eats too much. How can I talk with her about it?”

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 the Practice Workbook, Vol 1). I will summarize the important points here and provide more guidance on handling these sticky situations.

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 making referrals.

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 little girl.”

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 contact her.”

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 toast?  Some 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 #59.

It can be painful to watch loved ones eating in ways that you know jeopardizes their health.  Becoming 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 needs. 

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Tip #95 The Power of Reflecting

You can’t fake listening.
It shows.
Raquel Welch

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 most effective.

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.

• Double-sided: You reflect both sides of the client’s ambivalence. (See Tip #55, Ambivalence)

• Reflection with a reframe:  By your 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 #72, Summarizing)

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 other people.”

Simple reflections: “You like walking.” Or “You know walking would help bring your blood pressure down.”
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 a habit.”
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 about change.  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 #69)

• 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 them. 

• 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 advice.”

• 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 powerfully. 

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Tip # 96 Developing Discrepancy

If you’re doing something that does not make sense,
look deeper: It makes sense.  
Geneen Roth

When we are no longer able to change a situation,
we are challenged to change ourselves.
Viktor Frankl

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 appropriate clothing.  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 now.

Some examples of discrepancies in our work:

• A desire to be healthy for the sake of a spouse and high blood sugars that will lead to complications.
• A self-perception as a cooperative patient and very few food records filled out.
• A belief that God wants him to take good care of his body and a high waist-to-hip ratio.
• A 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:

• “If you keep eating this way, you will end up on dialysis.”
•  “Can’t you see that all these processed foods contribute to your high blood pressure?”
• “Do you really believe that your weight is not affecting your health?”

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 over:

Elicit values and desired goals with open-ended questions.

• “Tell me what concerns you most about your blood pressure.”
• “What do you see yourself getting from weight loss?”
• “How do you see yourself two years from now?”
• “What kind of person (wife, parent or citizen) do you see yourself as?”

Reflect what 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 environment.

• “You care a lot about your children and really want to be around for them.”
• “You like to see yourself as a person who takes good care of himself.”
• “Being a mostly healthy eater is how you see yourself in the future.”
• “You 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.”
• Being seen as a cooperative patient is one of your values.”

Summarize 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 your kids.”

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.

• “How does all this look to you?”
• “What kind of eaters would you like your kids to be when they grow up?”
• “Tell me how you see your life five years from now, assuming you keep doing pretty much what you are doing now.”

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 Tip #55.)

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 comfort.

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.

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Tip # 97 Shame and Guilt

Humility is wisdom.
Shame is not.
 Thom Rutledge

  Positive guilt occurs when we begin to
break rules that need to be broken.
Dede Beasley

Guilt and shame often arise in nutrition counseling, so it’s useful to understand these feelings.

Guilt 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 see:

• A client who experiences guilt at having one bite of a cookie based on the belief that this will cause a blood sugar spike.
• A 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 follow-up appointment.
• Sometimes 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.

In 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:

• A 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.
• Shame over excess weight or over a chronic condition such as diabetes may keep a person from engaging in life.
• Clients who have difficulty eating in public are likely experiencing shame.  
• Many 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 depression. 

What you can do to address guilt and shame:

• 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 scale.
• 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. 
   

A special thank you to Linda S. Ber, RD, LDN, CDE, who helped me tweak this Tip.

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Tip # 98 Making Referrals

I not only use all the brains I have,
but all I can borrow.
Woodrow Wilson

I think knowing what you cannot do
is more important than knowing what you can.
Lucille Ball 

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:

• A 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.
• You 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.)
• A 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 new one.
• 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.
• You have decided to limit your practice to diabetes and weight management. A client calls for a consult on food allergies.
• A 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).
• You 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 life.  
• An 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 person.
• You 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.

• Reflect 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 your diabetes.”
• State 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 management goals.”
• Ask 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 information?”
• Wait for a response before giving the referral.

When the referral is for your own reasons, keep 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).

• “That is a practice specialty that I don’t work with. I want you to have the very best dietitian.”
• “At this time I am not taking clients in your daughter’s age group.”
• “I 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 questions.  This 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.

A 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, practice.

• When 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.
• When 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.
• When 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.
• If you feel guilty about sending a client away, remind yourself that professionals find the very best care for their patients.

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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? (in Practice 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, in Practice 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, in Practice 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.” 

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