May 21, 2021

I am announcing today that I have set up the Molly Kellogg Nutrition Counseling Fund through the Academy of Nutrition and Dietetics Foundation. The fund will help advance counseling skills excellence in the dietetic profession by providing financial support to Dietitians and Diet Techs who are pursuing continuing education or research in the nutrition counseling process. Preference for these awards will be given to diverse applicants from underserved populations and/or those who employ a Health at Every Size (HAES) approach.

This Fund is the culmination of a career-long goal to give back to the profession that has given me so much. It will provide opportunities for a younger generation who have the same passion and desire as I do to help others through quality nutrition counseling.

Over the years, I have heard from so many of my you who have told me how much you appreciated and benefited from my work, whether you attended a lecture or training or utilized my resources. Great, the verbal feedback is gratifying. Now it’s time to put your money where your mouth is by growing this Fund with your donation.

My hope is to leave a legacy that will continue to advance excellence in counseling in the dietetics profession for years to come.  If I was ever able to help you along your career path, please consider paying it forward with a donation to the Foundation. I’ve made it easy; there is a link on my site here.

A few more words about how an endowed fund works. This is a permanent fund so it will function on into the future. Each year the fund will give five percent of its value to worthy applicants. At its initial value, this will allow up to $5K of scholarships or grants each year. I’d love for the fund to be able give out more than that. You can boost the fund’s endowment (and therefore how much gets awarded each year) by making a donation. All donations are tax-deductible.

Everything you donate will go into making the endowment larger. So, for example, if you donate $100, this will allow $5 more each year in grants year after year. If you donate $1000, $50 more will go to grantees for years to come. I’d love to see both small additions to the fund and larger ones from those of you who have the means and know how important it is to give back to future generations coming behind us. If you agree with me that this is a worthy cause, this is the easiest way for you to endow it for many generations to come.

If you are an Academy member and wish to donate on-line, click here.

If you are not an Academy member or wish to mail a check, here is the donation form.

January, 2021

Dear friends and colleagues:

2020 has been a year of reckoning for many of us. We’ve been forced to shift much about how we live and work. For me, the timing has been perfect to step back and take a look at what I’m doing and where I’m going. As I end my 6^th decade, it’s time to travel less for work and to turn over to younger trainers the joy of sharing MI with health professionals. It’s time to phase out my MI training career while I continue and grow in my psychotherapy practice.

The world is full of suffering.
It is also full of overcoming it.
Helen Keller

The important thing in science is not so much
to obtain new facts as to discover
new ways of thinking about them.
Sir William Bragg

Sometimes we need to bring up an important topic that we believe the client may not want to discuss. Here is an extended format for these tough situations where you know or suspect that your client has no intention of making any changes and you feel you must try to make an impact. It was originally developed for clients engaging in harmful or dangerous behavior (e.g., drug use or smoking). Nutrition professionals will find this process useful with a client whose health is imminently impacted by diet. For example, a patient is readmitted for chronic heart failure and has been consuming a high sodium diet.

As with any effective counseling strategy, this format is embedded in an atmosphere of collaboration, assumption of client autonomy, wishing to hear the client’s perspective and compassion. The conversation is opened by the counselor asking permission to discuss the topic. “Your doctor has asked me to speak with you about how you are eating. May we do that for a few minutes?”

The acronym FRAMES is used to remember this model:

Feedback: Give feedback on the risks and negative consequences of the behavior. Seek the client’s reaction and listen. “This fluid accumulation that caused your doctor to bring you in here is due to salt in your food. Each time fluid builds up it causes damage to your heart. What is your response to this information?”

Responsibility: Emphasize that the individual is responsible for making the decision about behaviors. “It’s entirely your choice how you pick your foods. It’s my job to provide information to help you make these choices that affect your health.”

Advice: Give straightforward advice on modifying behavior. “This list of foods includes the ones that contain enough salt that fluid builds up.”

Menu of options: Give a menu of ideas the client may choose to pursue. This fosters the client’s involvement in decision-making. “Some of my other patients learn new ways to cook, or how to choose foods at the market, or how to get less salt when eating out. Tell me which of these approaches interest you?”

Empathy: Be empathic, respectful and nonjudgmental. “This condition is tough on you and I want to hear what this all means to you.”

Self-efficacy: Express optimism that the individual can modify her behavior if she chooses and that the desired result will follow. “I know it is possible to make simple changes that will allow you to stay out of the hospital.”

Many of our clients come to us with what sound like clear health goals. They may want to eat healthier, get off blood pressure medication, or fuel up for the next marathon. When a client has stated the direction she wants to go, our job is to help guide her toward the behaviors that will get her there. Tip #116, The Process of Focusing, explores our role in guiding clients from their overall direction to specific behaviors that will likely achieve success.

This tip originated in a conversation I had with a couple of participants in my Motivational Interviewing training, and then other colleagues chimed in to add depth. It began as we realized that the recent proliferation of communication platforms has encouraged us to change our style.

I got a question recently about adapting Motivational Interviewing to other cultures, especially with Hispanic clients in a WIC clinic. The dietitian had noticed that some clients didn’t seem to understand the idea of setting a goal. She asked if it would be better for the clinician to state a few things that the client might want to consider working on and then ask for feedback.

We all have our ups and downs. Some days we wake up clear-headed and ready to take on the world. Our work flows easily, we feel confident, and we get positive feedback from those around us. And then there are the days when we seem to get out on the wrong side of the bed, and we dread going to work. Or the day seems to be going well, and then you realize you are “off” and you are not sure why.

Motivational Interviewing is powerful in enhancing motivation to change. This happens when the counselor listens for and brings out preparatory change talk (desire, ability, reasons, and need). When enough of these have been said, the client may naturally move into mobilizing change talk, such as activation and commitment. The more change talk in a session, the more likely the person is to make the change. In previous Tips, we’ve explored the various types of change talk, how to elicit more of it, and how to best respond to it (Tips #69, 110, and 121). Here we focus in on the change talk that tells us a commitment is being made.

Is a motivational interview an appropriate process to use when talking with a person who is considering using your services and has not yet decided? To answer this question, let’s look carefully at motivational interviewing.

Motivational Interviewing was first developed in the addictions field for work with clients who were deeply ambivalent about making changes. Because of the complex nature of disordered eating, our clients are often of two minds about making the changes necessary to recover. No matter your take on whether eating disorders involve addiction, the illness is a complex process that involves specific behaviors.

Are you a nutrition counselor and using MI when it seems to fit? If so, your sessions may be more effective than before you learned about MI. They can be even more effective when you make the final shift to conducting an actual motivational interview in your nutrition setting. There is a difference, and it matters.

We take breathing for granted; it's there all the time. Even when we're not paying attention at all, it's there supporting us. It is one of the few physiological functions that is both involuntary and voluntary -- we can alter it when we choose to. There are many practices and religions that use breath control as a practice. For example, various types of breathing are used in the yoga tradition. Specific breath practices can cool us or warm us or activate more energy or help us calm. Here, I will be focusing on the ways in which attending to breath can be of value to us and our clients.

I was asked recently what to do when we hear clients criticizing themselves. What is a motivational-interviewing-consistent way of addressing this phenomenon?

The familiar phenomenon called impostor syndrome occurs when you believe that you’re inadequate and a failure in the face of evidence that you’re skilled and quite successful. At least 70% of people experience this feeling at some point.

All clients will voice their reasons to not make changes. This is normal. It simply shows us that ambivalence is present. In Tip #101, I described sustain talk, and in #174, I explored some effective ways to respond when we hear it.  Here, we look at another, more advanced, way to respond.

There are many reasons to conduct nutrition counseling in a client’s home. The most obvious is that homebound patients can’t come into your office. If you work for an infusion company, you may consult in the home for TPN or tube-feedings. Other reasons are for pediatric early-intervention programs where most services are provided in the home. You may offer kitchen makeovers that require your being in the kitchen, and finally, you may want to avoid the overhead costs of maintaining an office.

Gratitude is the feeling of appreciation for something. It emerges naturally when we are glad for something we have received. It implies acceptance.

This Tip is a continuation of a theme begun in Tip #173. Here we take a slightly different perspective.

I am often asked how to use the effective skills and spirit of MI in brief health settings. In Tip #126, I shared a simple format based on MI called Brief Action Planning. This format keeps you focused and moving forward with clients who have at least some readiness to change.

(This is a revision of Tip #83, first published in 2009)

Nobody’s perfect. We have all goofed at times and regretted something that cannot be taken back. Some examples:

• You gave the wrong information to a client.
• You double-booked or missed an appointment.
• After a session, you realize that you missed an important piece of education.
• There was a misunderstanding about appointment time, length, fee, expectations or your policies.
• Confidentiality was breached.
• You get feedback that you inadvertently hurt a client’s feelings or offended him.

We often hear very critical self-talk from our clients: “I am so stupid.”  “I’m a pig.” “I’m lazy,” “I was bad this week,” “I hate that I ate that ice cream,” or “I should have stopped at one serving.” It’s tempting to argue with the person: “Don’t be so hard on yourself” or “Making that choice doesn’t mean you are stupid.”  This tends to strengthen the client’s critic.

Wanting to change a behavior generally begins with disliking or even hating the behavior. This often gets mixed up with hating ourselves. Ironically, hating ourselves does not support the process of change. It has the opposite effect and keeps us stuck. Compassion for ourselves is the first step to real change. Unfortunately, self-hate is common among our clients, and just telling them not to hate themselves gets nowhere. Another option is to turn toward a troublesome behavior with acceptance. People often resist acceptance because they see this as saying they like or even condone what is happening. In this Tip, we look at acceptance as a step toward real change.

When health professionals take on the process of motivational interviewing, we enjoy the client-centered paradigm. As we use the skills within the spirit of MI, the client takes a more active role, and therefore change is more likely.  We also discover that it allows us to work less hard, the sessions go more smoothly, and we feel more successful. Then there are the moments when things seem to be going well, and a client says, “Just tell me what to do. You are the expert.” If you have fully taken on the spirit of MI, this can be disappointing and even upsetting. This is one of the most common concerns that comes up in my training workshops.

Sustain talk is anything the client says about not making the change you are talking about. This might be, “I can’t do that.” Or “I don’t want to join a gym.” Or “but that won’t work.”

We all have good and bad days. Think of those days when you feel alert and focused, confident in your ability to help your clients, calm and ready for whatever comes in that day. Then there are the days you wonder how they let you do this work, days you have trouble concentrating or you find the clients annoying. What’s up and how can you increase the “good” days?

A successful nutrition counseling session flows naturally through stages. In motivational interviewing, these are called the four processes. They are somewhat linear. A skillful counselor will circle back and move forward as needed. This deliberate shifting from one process to another is one of our most important functions as a counselor.

Reflections are the most effective of all the strategies in conversations about change. Here, we explore how to make reflections more powerful by making them more complex.

What does this do?

At a recent training, I was asked for examples of characteristics to affirm. The trainee was having trouble noticing strengths in her clients and wanted some ideas to get her started. I’ve included a list below.

I am often asked, “What should I do when a client sets a goal and I know it’s unrealistic?”

The client is the only one who knows for sure whether it’s realistic. Your experience with other clients may tell you that it is unlikely he will follow through. If you get that intuition, you could ask to explore this goal a bit.

If you have been a nutrition counselor for a while, this situation will be familiar to you. The client has an insight or comes up with an idea about how to handle something that is obvious or old hat to you. For example, a client shares a revelation that she could plan out her menus over the weekend to support her making healthier choices. She is pleased with her brilliant plan. You have heard this idea many times and often suggest it to your clients.

How often have you heard, “He’s a control freak” or “I don’t have a choice”? These are common statements that show how important control and choice are in our lives. We humans do like control. When we have a degree of control over our environment, we are safer and we are more apt to get our needs met. So, of course, we prefer this. We naturally dig in our heels and resist when we sense that our control is being taken away or when we have few, if any, choices. Looked at this way, resistant behaviors can be seen as survival reactions.

One of the core Motivational Interviewing values is supporting the client’s autonomy. In addition, our job is to direct the session toward changes that will serve the client’s best interest. How do we find the ideal balance between accurately following the client and directing the session? The answer is to strategically listen, reflect, summarize and ask.

It’s not easy for most of us to sit with silence. Like “dead air” on the radio, it just doesn’t seem right. It may seem as if nothing is happening and time is wasted. When someone is considering or planning the process of change, silence is essential. It allows space for the internal work necessary for real shifts in attitudes and behaviors.

In a recent email, a dietitian asked me what to do when a return client says he is doing everything he is supposed to do and yet a careful assessment shows he is hardly following any of the recommendations. The client actually seems to believe that he is doing just what he is supposed to do. The dietitian wrote, “I feel there is a disconnect somewhere.” There is indeed a disconnect. Your job is to help the person see it and to support a move toward change.

I am often asked about interrupting clients, whether to do it and how. This is a complex issue that does not lend itself to easy answers. Personal style (yours and the client’s,) cultural differences, the setting, and even your mood will affect this process. Here are some general guidelines to think about.

A recent listserv post was intriguing. The writer wondered if she should have asked a widower how his wife died. She thought he might be offended if she did not ask. She also felt that knowing might give her some insight into what’s happening with him. I gave her my simple take: “Ask yourself: Is this critical to helping him with his nutrition goals? If yes, go ahead and ask. If not, contain your curiosity and move on.” After I clicked “send,” I realized that this is a complex issue.

What sort of person are you while you are working with a client? What characteristics are most present? What part of you is running the show? If you are like most of us, it will shift from time to time.

Evocation is both one of the four MI processes and an essential spirit element. It is evidenced by the clinician working to evoke the client’s reasons for change and ideas about why to change and how to do it. There is much more calling forth reasons and ideas from the client than offering of suggestions by the clinician.

Compassion here is not a feeling on your part. You may feel sympathy and kindness toward your client. This is not compassion. This MI spirit element is evident in your actions. You are guided by the needs of the client. You commit to work for the well-being of this person.

The element of the MI spirit called affirmation consists of the overall view we take of the client. We search for what is right rather than what is wrong. We notice efforts being made, even if small. This encourages more small steps that lead to real changes. When we tune in to strengths this person has, we support her and her confidence on this journey toward health.

Fully accepting the autonomy of our clients is an essential element of the spirit of Motivational Interviewing. The client is the boss of herself and her family. The ultimate choices are hers. It is not your job to force her to do anything. You are there to support the client as she considers making lifestyle changes. When you attempt to force someone to do something whether in language or coercion, it doesn’t work and even backfires. The natural desire to assert freedom causes the person to react in ways that we see as resistance.

In this element of the MI spirit, the clinician strives to understand the client’s point of view as accurately as possible before asking the client to consider change or offering anything.

In this aspect of the Motivational Interviewing spirit, the clinician conveys a belief in the inherent worth of the person. This one can be a challenge, especially if you work with clients from a large variety of backgrounds. It is easier to value the worth of someone who is similar to you. Unfortunately our minds tend to undervalue characteristics that seem different to us. It can take extra effort with some clients to hold a belief in their innate worth.

The first element of the Motivational Interviewing spirit is partnership. The session feels like a collaboration from beginning to end. You and the client are a team working together to address the client’s problems. There is power sharing rather than an expert/client imbalance of power. The client’s expertise on his life is accepted and evoked at least as much as the clinician offers advice.

One of the aspects of Motivational Interviewing that makes it so powerful is the spirit. MI is not just the techniques such as open questions and reflecting. The spirit, or feel of it, is just as essential. Listening to or watching an MI session, you sense this spirit. The client does, too. I often hear something from those who have attended my trainings. After they return to practice, an ongoing client will say something like, “Oh, I liked that. This was a good session!” This is the result of the MI spirit shining through.

First find out how the client uses technology. It can be tempting to suggest the latest app or a technology that works well for you. Instead offer to use it in ways that fit for this person and support her journey to health and a healthy relationship with food. Here are some examples.

”Read

Affirming is one of the fundamental Motivational Interviewing skills. It supports engagement, encourages the client to further explore the change process and builds confidence. To form an affirmation, find an effort the client is making or a strength you notice and reflect it back to him. It’s often that simple. Tip #63 (in Practice Workbook, Vol 3) has more basics on affirming and some examples. In this Tip, we look at ways to craft affirmations to make them most powerful.

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As nutrition professionals we are trained to assess our clients’ nutritional status and determine the best treatment for the nutrition problems we find. This means focusing on what’s wrong. We understandably use our corrective lens. This is appropriate and useful in our role on the medical team.

When we move into an outpatient setting in a clinic or private practice, the medical model is not enough. In these settings we encounter people with their complex experiences, beliefs and desires about health and food. In order for them (and us) to reach our goals, behavior change needs to happen. We, of course, want to change the client’s behavior. When we act on this wanting to change someone’s behavior, it is called the righting reflex. Wanting to change someone’s behavior is normal. How we proceed will affect whether change happens.

Making profound change is not easy. We know that obstacles to making healthy changes will arise. It is natural for us to focus on these obstacles. We want to help our clients and see ourselves as problem-solvers, so we look for the problems. The client may focus on them, too. Anticipating and addressing them are essential; when and how we do it matters.

What we do and say at the beginning of a session matters. We set the tone. Embodying the spirit of Motivational Interviewing from the very beginning makes the rest of the session smoother.

I’ve written many Tips on giving advice. As nutrition counselors that is an important part of our job. To summarize:
Motivational Interviewing offers us this format for most effectively couching our education:

• Elicit what the client already knows and/or needs from you.
• Provide the information in a neutral manner.
• Elicit the client’s response to the information.

When we provide advice to our clients, we make sure it is based on solid scientific evidence. What about how we deliver the advice? Is there evidence that can direct us here? Indeed, careful Motivational Interviewing research on specific wording does tell us what works and what doesn’t.

Do you have a colleague who wants to practice counseling skills as much as you do? Great! Here are some ways you can help each other.

I am often asked how to most effectively work with interpreters.

We talk in nutrition counseling sessions and the client talks, too. What is an ideal relative amount of talking for each of us? First let’s look at the various reasons you may talk.

Motivational interviewing is a carefully researched model for change conversations. One of the parameters measured is the counselor’s ratio of reflections to questions.

As counselors, we strive for accurate empathy. We listen carefully and reflect back what we hear that seems important.

Making real, lifestyle change is tough and usually involves many steps and setbacks. To make the permanent changes we recommend takes persistence on our client’s part and ours.

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.

Here we look at how the four processes of MI (Tip # 114) support a nutrition counseling session based on the HAES® paradigm.

This Tip continues to explore the Health At Every Size ® paradigm and how it fits with motivational interviewing.

The Health At Every Size (HAES ®) approach to health and weight has been around for several decades. It also has been called the non-diet movement and size acceptance.

Many of us went into the field of nutrition because we want to help people. In our training, we learned about the impact of food intake on medical issues so as to make people’s lives better.

A few weeks ago in the middle of an initial session, I realized that my attention was on the problems with how the client was eating and the way she was thinking about her body and food.

We are in the business of helping people make positive health changes. Reluctance to make these changes will inevitably arise. Let’s pick apart what we often call resistance to understand it better.

In some nutrition counseling settings, clients have not chosen to meet with you. They have been told to or even coerced.

The specific skills we employ in our sessions allow us to effectively guide our clients toward positive health behavior changes. Most of these Tips are devoted to strategies and skills.

If you have chosen to transition your counseling style toward motivational interviewing, you may find that note-taking feels as if it detracts from being present with your client.

Brief Action Planning (BAP), developed by Steven Cole and others, is a communication format based on motivational interviewing and designed for health care settings.

As nutrition counselors, our goal is to help people attain better health through diet changes. We do this by engaging, focusing, evoking and planning.

Webster’s dictionary defines resentment as “a feeling of indignant displeasure or persistent ill will at something regarded as a wrong, insult, or injury.” It is very uncomfortable and yet can be useful if we attend to it.

In the last three Tips, we have looked at important processes that occur in all motivational interviews. The first three processes – engaging, focusing and evoking – are always present in true MI sessions.

Tip #114 introduced the four processes that are now used in the collaborative conversation called motivational interviewing: engaging, focusing, evoking and planning. Here we take a closer look at the evoking process.

Change counseling is most efficient and most effective when a clear focus is agreed upon.

In the last Tip, I introduced the new four processes used in the collaborative conversation called motivational interviewing: engaging, focusing, evoking and planning.