In this age of multiple forms of electronic communication, the traditional office visit is not the only way to provide nutrition counseling. E-mail, phone, voice mail, webcams, chat rooms, blogs, text messaging and Twitter are all ways to communicate with clients. This Tip addresses the use of phone sessions used either alone or as an adjunct to office sessions.
For me, words are a form of action,
capable of influencing change.Ingrid Bengis
Desire, ask, believe, receive.
Stella Terrill Mann
Advantages of phone counseling:
Clients do not need to travel. This saves time and gas money and is more convenient. This is particularly useful for clients who live in remote areas and are not able to access professional nutrition counseling in person.
You may save on office expenses and professional clothing. If all your work is by phone, you do not need a professional office and you can work in casual clothing (or pajamas).
You may be able to charge less for your services because of these savings.
Appointment times can be more flexible and spread throughout the day since you do not need to be in an office.
Geography doesn’t matter! It is possible for you to work with people all over the world. If you have a niche specialty, such as PCOS or food allergies, by phone you have access to a much larger clientele than you do in your local area.
It is “green” since gas is saved and all records and handouts can be electronic.
If the client has a question about a specific product, you can ask him to get it and read the label to you.
Some people are more relaxed on the phone. They may share more openly than in person.
You could choose to allow clients to call you spontaneously when a question occurs to them or they need support to make positive choices.
If you get bored easily in your work, having some sessions in person and some on the phone may be more interesting for you.
You can continue to work with a client who moves. Many dietitians who treat eating disorders find this works well when a client goes away to school or moves to another state. A long-term trusting relationship plays an important role in recovery. If the client moves, she does not need to get to know a new dietitian. This works well only if the client is fully engaged in recovery and you have developed a trusting relationship. For clients still in some denial, a referral will be more appropriate.
Since the client does not see you, any issues that might arise about your size or shape will not come up.
For some low-literacy clients who are stronger in verbal skills, more frequent, shorter phone calls can be more effective than longer office sessions.
Voice messages can be a useful addition to in-person sessions or phone sessions. A client can give you quick updates or you can leave answers to simple questions.
Disadvantages with some suggestions for coping:
Many insurance companies will not cover counseling that is not in person. You can address this by being explicit about it and offering choice. For sessions the clients want covered by insurance, they come into the office, and for ones they are willing to pay for, you offer either office or phone sessions. For clients who want more sessions than are covered by insurance, you can spread out the in-person paid sessions and alternate with phone contact that is billed separately. Consider package rates that include a variety of ways for clients to access your services.
You may find yourself making the times so flexible that your life is disrupted and work time bleeds into off time. You then will likely not provide the best service. Set the limits you need to do your best work and to care for yourself. Having a separate office phone number is essential. Even if it rings in your home, answer it only at times that you are prepared to work. If you don’t have an office, it is still appropriate to have a separate phone number for professional calls, even if it is a cell number. For more on setting limits see Tips #21, Time Boundaries, and #22, Burnout.
Clients might take advantage of phone access to you. It is a challenge to provide what each client needs while still making a living and not becoming resentful. The informality of phone sessions may make this more challenging. When you begin to feel resentment toward a client for the time she takes, this tells you it is time to set more limits. Over time you may choose to set specific limits on the number of random calls.
While it is great to be able to work wherever you are and in whatever clothing you feel like wearing, this informality may affect your professionalism. It may be tempting for you to do things that you would not do with a client in the room, such as check e-mail. To avoid this, set up your space to support you. For example, sit in the same chair you do for office counseling, or if at your computer, open only the programs necessary for this client and have visible only written materials for this client. I find it useful to have a picture of the client visible.
Some people are just not “phone people.” They are uncomfortable using the phone for anything beyond short, concrete needs. If you are one of those people, phone counseling will likely not work for you. Some clients will just not be able to warm up enough to use the phone effectively. It is useful to discuss this with clients on their initial contact with you. You could ask: “How do you feel about having long phone calls? Are you someone who likes to talk on the phone?”
Sometimes cell phones cut out or voice quality is not ideal. There may be distractions on the client’s end such as room noises, dogs, or family members. You may insist that a land line be used and that the client find a quiet time and room where he will not be interrupted. You can set expectations for phone sessions, just as you might insist children be left at home when a client comes to your office.
You may need to see the client to conduct a visual assessment or you may need to weigh the client or get other measurements. Any time you feel you are not able to do an adequate job because of these limitations, you can insist on at least one office visit. Some clients may be able to weigh themselves and report to you. This is generally not a good idea for a client with an eating disorder or a weight-management client who is overly focused on the number on the scale. It can work with a client with whom you have an ongoing trusting relationship and who is in the final stages of recovery. The use of blind weights in nondiet or eating-disorders work would be possible only if the client could be blind-weighed by a third person who would report to you. See Tip #74 for more on blind weighing.
You don’t have the visual feedback that you would in an office visit. For example, a client may not like one of your suggestions. In person, you would be able to pick this up from nonverbal cues and switch to open-ended questioning. To effectively track your client’s responses with no visual clues, check in more often about the direction you are taking, the client’s goals, what she wants, and what she means. Keep checking in! When doing a piece of education, stop and ask for response often. You may feel as if you are working harder. It is certainly different from one-on-one and takes practice. Remind the client that you cannot tell whether she likes your ideas unless she says something. Some clients will give voice clues, but most will not. See Tip #4 for more on asking for direction.
Time can feel less structured than in an office visit where your client may be aware of the next client in the waiting room. Structure phone sessions more carefully than office sessions. For example, you might divide up the time and set a certain number of minutes reviewing the last week and food records, then a section for education and then begin talking about goals by a certain number of minutes from the end. With new clients, it may be necessary to be firm about this structure until they get used to it. For more on setting time limits, see Tip #21.
Clients may be more apt to forget calls. If you call them, they may be caught off guard. One way to avoid this is to have clients call you. This is similar to an office visit where the clients are expected to remember the appointment and get there. Treat phone sessions as you would office visits with the same no-show or late-cancellation policies. Some clients will want a text or e-mail reminder, depending on their favored form of communication. For more on this, see Tips #34, Discussing Fees, and #51, Setting Professional Limits Around Fees.
Phone sessions can be taken less seriously. Many people are accustomed to talking on the phone while doing other things such as cleaning dishes or going for a walk. Of course, a client would not do this in your office. You may be able to tell when a client is multitasking because she will miss some of what you say. Setting ground rules may help. For example: “I find it is most effective when my clients set aside the time for our phone session and sit down with nothing but their notes in front of them.” The request for phone sessions when it is not absolutely necessary could signal a lack of commitment to this important process of behavior change.
The client may not be prepared for the call. Of course, this can happen at office sessions as well, but may be more common on the phone because phone calls take less action on the client’s part. Defining the sessions and asking for specific preparation from the client may help. For example: “So next time we have agreed to spend some time on portion sizes and you are going to make the call in your kitchen so you can measure your plates and glasses.” You may need e-mailed food records or for the client to do some reading. When clients don’t do the preparation you expected, revisit their readiness to change (Tip #7). You may also find it useful to open a discussion by asking, “May we review how we are doing these calls to make them most effective for you?”
When you are not in the same room with your client, you cannot both look at a piece of paper or food model at the same time. If you use food records and/or handouts a lot in your work, you may need to require your clients to be at a computer with a good Internet connection during the call to allow you to review records and to send them materials by e-mail.
In summary, your role in phone counseling is not exactly the same as in office sessions. You may find you need to deliberately “shift gears” if you do both office and phone sessions. Find what works to support you to stay in your counselor role while on the phone and stick with it. Remind yourself to provide more structure and ask for feedback. It is OK to admit to clients that you are experimenting with phone counseling and want feedback about how it is working (or not) for them.
Thanks to these colleagues who contributed ideas for this Tip: April Ahrendt, Aimee Bert-Moreno, Lauren Cohen, JoAnn Cooper, Alice Covey, Joanna L. Kriehn, Theresa Logan, Jan Patenaude and Elyse Resch.