Tip #138 Working with Discord in Health At Every Size ® Counseling

We all encounter clients who tell us that if they change their body (lose weight), it will change their life for the better and a focus on weight loss alone is all they wish from us. MI reminds us that arguing will get us nowhere. It will only bring up more of the same.

Whatever the present moment contains,
accept it as if you had chosen it.
Make it your friend and not your enemy
and your life will change.

Eckhart Tolle

We either make ourselves miserable
or we make ourselves strong.
The amount of work is the same. 

Carlos Casteneda

Here is an example of a session that gets off track as the counselor holds her belief in HAES above her commitment to client autonomy (Tip #128.) Shemisses opportunities to engage with the client.

Client: I really want to lose weight. Every time I do I feel so much better about myself.

Counselor: It sounds like you have yo-yo dieted many times. How many times? (Closed question)

Client: Well, I wouldn’t really say it’s been that many.

Counselor: Well, you know that dieting just doesn’t work. At least 95 percent of those who lose regain it, so let’s focus instead on what you can do to stay healthy. (Advice without permission)

Client: I am healthy, now at least. That’s not the point. I need to get this weight off. I hate the way I look. I mean, look, it’s disgusting, and at this weight I can’t shop in the regular stores.

Counselor: Focusing on appearance doesn’t work in the long run. I can tell that you have gotten caught in the diet/binge cycle and there is only one way out. Focusing on eating what you really want and learning to follow your internal signals of hunger and satisfaction are how to get out of the yo-yo dieting syndrome. (Pushing one choice)

Client: What? If I ate what I wanted, I’d be a whale. That’s what I’m doing when I’m not dieting and you can see what happens.

Here the counselor provides uninvited opinions and advice and uses closed questions. The conversation quickly becomes an argument. The counselor is then further from engagement than she was at the beginning and the client is less willing to adopt a new approach.

How to approach this conversation in an MI-consistent manner? This would mean staying embedded in a belief in client autonomy and compassion for the client’s situation. You begin as MI always does, with engagement. The more you attend to “getting” your clients, seeing the world as they do, the less apt you are to veer off into argument. We don’t abandon our belief in the value of the non-diet approach. That faith is based on our experience and that of our past clients. Part of our role is to share our opinion. Within the framework of MI we don’t share our experience until we sense engagement and have permission to add our input.

Notice the difference here, when the counselor primarily reflects (Tip #95) and asks open-ended questions (Tips #60 & #108) and gives opinions and advice only after receiving permission (Tip #131). An assumption of client autonomy is assumed throughout.

Client: I really want to lose weight. Every time I do I feel so much better about myself.

Counselor: You would really like to feel better about yourself. (Reflection)

Client: It’s embarrassing for all my friends to see me regain the weight I lose. I want to lose it permanently this time, especially since my doctor says I may be headed for diabetes.

Counselor: Losing and regaining is painful, and you have a reason to focus on your health now. (Complex reflection)

Client: Yes, and I hate how I look.

Counselor: Your appearance is important to you. Tell me more about how the losing and regaining doesn’t feel so good. (Reflection and asking for elaboration)

Client: Well, I begin to lose weight and feel great. I’m proud of myself and begin to get compliments. But I feel deprived and the food gets boring. I slip here and there, and before I know it, I’ve gained the weight back. Then I feel worse than I did before. I’m good at so many things in my life. Why can’t I do this?

Counselor: You like the sense of achievement when you diet and you’ve also learned that depriving yourself backfires eventually. You want to find a way to be proud of yourself without feeling worse in the long run. You are someone who doesn’t give up when you really want something and you haven’t yet found a way to feel successful with your eating. (Summary from client’s perspective with a reframe)

Client: Yes, that’s what is so frustrating and embarrassing about this.

Counselor: Many of my clients have shifted their attention to health and enjoyment instead of weight, and it has improved their lives. Might you like to hear more about this? (Offering a fact and an open-ended question)

Client: Oh, so that’s what you do? Tell me about it.

Counselor: There is another path that leads to feeling much more competent about eating. By leaving restrictive eating behind, practicing eating according to appetite and focusing on finding foods that satisfy, people begin to be more comfortable eaters and also feel better about themselves. It’s your choice. What are your thoughts about this path? (Offering advice after permission followed by an open-ended question)

In this conversation, the counselor encourages the client to voice her distress and makes sure the client knows she heard it while highlighting the insights and concerns that might allow a paradigm shift.

What about when a client who has initially embraced the HAES paradigm, then voices ambivalence? This may sound like:

  • “That’s not going to work.”
  • “I am happier at meals, but I’m still eating too much.”
  • “This isn’t working. I’m not losing weight.”
  • “I’ve decided to go on this two-week diet that my friend told me about.”

The MI approach of rolling with what you hear fits well here.

  • “It’s your choice what ideas you try out.”
  • “You know yourself and what will fit for you.”
  • “You’re frustrated that your body remains the same size as you work to normalize your eating.”

After this initial coming alongside your client, offer to step back to take a look at the bigger picture.

  • “Tell me again (or more) about the effect of focusing on losing weight.”
  • “Tell me how this fits into your long-term goals.”
  • “Remind me of what you have learned over the years about what works for you.”
  • You might also provide a summary (Tips #72 & #119) of what you have heard that points up the client’s HAES process so far and how it seems to be getting off track. For example: “Let me summarize what I see here. You came hoping I would help you diet again. You realized that this dieting process doesn’t work in the long run and decided to give the new approach a try. As you have focused on feeding yourself in this new respectful way, you have noticed how much more relaxed you feel around food and that most of the time you end up eating less than you did when you were trying to diet. You have noticed that there are still times you turn to food for comfort, and we have just begun to look at other ways to care for yourself. Your blood sugars have been more consistent and your doctor agreed to not increase your medication. This week you had good news about your son getting engaged and this reminded you how much you would like to weigh less. This led you to think about dieting again. So, where does this leave you right now?”

The spirit, techniques and processes of MI support you as you gain skill in working with a HAES approach. Just as your clients work through many stages when shifting toward acceptance, you, too, can choose to see your process as a counselor as ongoing. Over and over you can revisit skills and concepts and practice them. As one skill or stance becomes second nature, you can look for another to practice.


Posted in Tips