Tip # 100 Structuring Sessions

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?

Those who fail to plan, plan to fail.
To simplify complications is
the first essential of success.

George Earle Buckle

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 client-centered.

Excellent templates and algorisms already exist for nutrition counseling. For example, the Nutrition Care 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 goalswith the client rather than for the client. Bauer and Sokolik’s textbook,Basic Nutrition Counseling: Skill Development ( Wadsworth , 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.

  • Exploring 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.
  • Elicit/Provide/Elicit: 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.
  • Change 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.

When 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 summarize.

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