Today’s article is the ultimate intersection of theory and practice with the singular goal of helping YOU to become a better nutrition counsellor.
Current dietitian ( ME!) and future dietitian and master’s student ( Leigh) have come together to share some incredibly valuable insights on how to better connect with your patient/client and improve your 1-on-1 counselling ability.
The target audience for today is primarily nutrition students, interns or very young/new dietitians who feel they have room to grow as nutrition counsellors.
Our ability as dietitians to effectively encourage dietary improvements depends largely on our aptitude as nutrition counsellors.
How can we make the most of the limited time we have with our patients/clients and ensure that what takes place in an appointment is ultimately translated into behaviour change in the real world?
That is the exact question that Leigh and I will be addressing today, but we will be addressing it from different angles.
Leigh, from a theoretical angle having recently completed a workshop on Motivational Interviewing and read a book devoted to the practice.
Myself, from the practical perspective having two years of private practice counselling experience in weight management under my belt.
We will draw from both these areas to provide a comprehensive tips on how young and aspiring practitioners can greatly improve their counselling skills and effectiveness.
When Theory Meets Practice: 5 Steps Towards Improved 1-on-1 Nutrition Counselling
Leigh Merotto & Andy De Santis
Before we go any further, Leigh is going to define Motivational Interviewing ( MI) for us.
What is motivational interviewing?
Motivational Interviewing is a proven counseling approach focused on collaboration and partnership, developed by clinical psychologists William Miller and Steven Rollnick in the early 1980’s (1). It has since been evolved and refined, making its way into many disciplines, including drug and alcohol abuse therapy, fitness and sport, and increasingly so, nutrition and dietetics. As opposed to a traditional ‘directive’ approach that involves simply telling the client what they need to do, motivational interviewing uses a ‘guiding style’ that is meant to strengthen motivation and develop strategies for change within the client themselves (2). It is a communication style that focuses on drawing out an individual’s own reasons for change within an atmosphere of understanding and compassion (2). Motivational interviewing has been proven to establish lasting behavior change for clients, and as quoted in the book by Dawn Clifford and Linda Curtis (2016), “MI is for professionals who care about the success of their clients … for years to come”.
5 Steps To Superior Counselling From Through Motivational Interviewing
There are some key take-aways I want to share with those of you reading that are also interested in learning more about motivational interviewing. I have created a list of what I think are the top 5 lessons you can take with you to use in your professional practice, to help your clients or patients achieve lasting health behavior change.
#1 Establish A Partnership With Your Client ( Leigh)
The spirit of MI is to embrace partnership with the client: the practitioner collaborates with the client to develop strategies and goals that are individualized. Through partnership, the practitioner avoids what Miller and Rollnick (2013) call the “expert trap”, which occurs when the practitioner gives the impression that they have the solution to all the client’s problems. Rather, the practitioner works with the client, and views the client as being equally as knowledgeable. Although the practitioner is more knowledgeable on nutrition evidence and strategies for change, the practitioner respects that the client is an expert on what will fit into their lifestyle.
What This Looks Like In Practice ( Andy)
In my experience one of the best ways for a practitioner to develop rapport with a client is to quickly determine both a client’s goals and also their expectations.
Each client comes in to your office with their own unique goals and expectations.
Your job is to figure those out as soon as possible and use them to frame the entire session.
So what’s the difference between a goal and an expectation?
Goal: What the client ultimately wants to achieve in seeing you ( ie: weight loss or gain, reduced cholesterol etc). It also helps if you let your client know YOUR goal for them, which should inevitably be to help them reach their goal in the healthiest, most balanced manner possible.
The question to ask: ” What brings you to see me today?””
In asking this question, you also actually address another principal of MI which is Evoking “Change Talk”. That essentially means that you get your client thinking about the deeper reasoning behind their seeing you and you can always relate your guidance back to this original goal and motivation.
Don’t just tell someone to eat, or not to eat something, but explain precisely why making that choice is directly related to their goal.
If you are able to do this, you will develop a much stronger rapport with your client because it allows them to feel you always have their goals top of mind.
Expectation: How the client wants you to help them reach their goal. Some clients want to know exactly what to eat and when to eat it, some want to make small changes to their current diet while others want to completely turn everything upside down. You need to identify, acknowledge, respect and deliver on your clients expectation in order to truly develop a strong partnership.
The question to ask: “What are you hoping to get from me/leave with today?”
#2 Practice With Compassion And Acceptance (Leigh)
We can maintain an aura of compassion if we try to see things from the client’s perspective, honoring that these life variables are not simply excuses, but genuine barriers and obstacles to work around (2). The practitioner communicates acceptance of the client-practitioner relationship through respecting absolute worth, by treating each individual fairly, regardless of their demographic background, socio-economic status, lifestyle choices, etc (2). Showing empathy is also really important, attempting to understand and gain perspective on what the client is feeling and thinking, by putting yourself in their shoes. Empathy is demonstrated through active listening, a calming presence, inviting the client to share more, by providing supportive facial expressions, and a calm tone of voice (2).
What This Looks Like In Practice ( Andy)
As far as I am concerned compassion and acceptance should be “givens” when it comes to counselling your clients but it is an area of practice that we would all be better served by keeping these at the forefront of our minds.
One of the best ways you can demonstrate compassion is by urging your clients to share some of the challenges they have or currently face in achieving their goals and acknowledging the validity that these challenges posses.
What you might say: ” I appreciate how difficult it is to eat well when everyone around you isn’t concerned about healthy eating or supportive of your goals.”
” I can only imagine how challenging it must be to worry about yourself and what you eat when you have three little kids and most of the responsibility falls on you.”
I strongly believe and say to my clients that no matter what the challenge or barrier is that they face, that we can always work towards a solution together.
#3 Honor the client’s autonomy ( Leigh)
The practitioner accepts the client’s right to choose what works for them, and honors their autonomy by putting them in the driver’s seat from the start of a session (1). To do so, you (the practitioner) can begin a session by asking the client what topics they would like to focus on. As the session progresses, let the client express ideas and strategies that will work for them. When offering information or advice in response, a practitioner must avoid imperatives such as “you should do XYZ”, because it is directive and diminishes client motivation (2). Rather, ask the client what they plan to do or how they envision themselves achieving a specific objective ( ie: increasing vegetable intake). MI is considered a ‘guiding style’: the practitioner guides the client into creating their own plan for change. The client is the expert on their own life, body, and behaviors, and the nutrition professional is there to offer evidence-based information and recommendations while respecting the client’s autonomy to ultimately choose their course of action.
What This Looks Like In Practice (Andy)
It’s your job to identify the strengths and limitations of your client’s dietary pattern relative to their goals and lifestyle.
Once you share that assessment with the client, you can give them a great deal of power and autonomy by asking right off by the bat “What we can do to fix XYZ?” ( ie: a lack of vegetable intake)
That immediately gets the client thinking of practical solutions to their problems, but it will obviously help if you bring some of unique and clever alternatives to the table as well.
The more carefully you listen to and understand your client, the more effectively you will be able to come up with practical solutions.
The number one way that I respect client’s autonomy when proposing dietary changes is by asking them if what I am proposing is practical and doable for them.
Remember that what may seem like a completely reasonable and brilliant suggestion to you, may not be as appealing to your client.
The only way around this is to always defer to your client when finalizing nutrition objectives.
What you might say: “ It’s completely okay if you don’t like my suggestion, I don’t want to write anything down on this piece of paper that you can’t see yourself doing, let’s think of something that works better for you and your lifestyle.”
#4 Always, always, always use ‘reflective listening’ ( Leigh)
Reflective listening (also known as active listening) is a skill that everyone should use and master. Reflective listening involves fully concentrating on what the other person is saying, and then demonstrating that understanding through verbal and non-verbal cues. The practitioner uses reflective listening skills in order to reflect what the client is feeling and thinking, and verbally expresses this understanding back to the client (2). These reflections help the client to feel validated, heard, and understood, which helps foster a strong relationship with the client and foster a safe space.
What This Looks Like In Practice ( Andy)
Paraphrase, Paraphrase, Paraphrase.
Exactly what Leigh alluded to above.
Paraphrasing is a critical and potentially overlooked component of effective counselling
When you repeat back your client’s goals, challenges or beliefs back to them, it helps both you and the client fully understand how to proceed in the best possible manner.
If you are unsure of which direction to take with the appointment or the client may not be 100% clear in their goals and expectations, paraphrasing is an amazing way to re-adjust and re-frame the session and allows the client an opportunity to think more deeply about their goals and beliefs.
What You Might Say: ” So you mentioned earlier that you’ve been cutting out fruit to help your weight loss goals, could you share a little bit more about your motivation or reasoning behind that choice?”
#5 Use affirmations to acknowledge your client’s efforts, strengths & struggles ( Leigh)
The practitioner should always be listening actively for opportunities to provide ‘affirmations’ to a client. As defined by Miller and Rollnick (2013), affirmations are positive statements regarding one’s character or values that acknowledges their strengths and efforts. Affirmations should always be genuine, as well as dispersed throughout a session to constructively praise clients for positive attributes on the path to change. It is important to remember that an affirmation is different from a compliment, which is less complex, less contextual and less reflective. A compliment might be “you did a great job!” whereas an affirmation would be more like “Considering how busy your week and how much was thrown your way, you did a very good job of sticking to your goals.”
What This Looks Like In Practice ( Andy)
The most important thing you will take from today’s article is that, believe it or not, what your client has to say is pretty much always more important than what you have to say.
You should never cut a client off mid sentence ( unless extraordinarily strapped for time) just because you are eager to get your point across.
Dietitians love food and love to talk about healthy eating but a counselling session is about where your client is at and where they need to go, and not about showing off what you know.
The best way to show off? Truly understand your client’s current context so you can impress the heck out of them with nutrition solutions are a superb fit for their life.
- Miller, W. R., & Rollnick, S. (2013). Motivational interviewing: helping people change. New York: Guilford Press.
- Clifford, D., & Curtis, L. (2016). Motivational interviewing in nutrition and fitnessThe Guilford Press.