Counselling Skills for Dietitians

Judy Gable worked as a dietitian for many years, specialising in paediatrics in the 1970s and diabetes research in the 1980s. In the early 1990s she established the course in communication skills for dietetic students at King’s College and during the next ten years also facilitated introductory courses in counselling skills and assertiveness for dietitians. She continued to work as a counsellor in primary care until 2010. Tamara Herrmann has worked for many years as a GP/Community dietitian and during this time developed her interest in obesity, eating disorders and communication skills. Tamara now works in private practice as a registered dietitian and registered psychotherapist.

Foreword xiv

About the authors xvi

Preface to the third edition xvii

Acknowledgements xx

Introduction xxi

About the companion website xxv

Part 1: Using a counselling approach in patient‐centred practice 1

1 The dietitian 3

The role of the dietitian 3

Using a prescriptive approach 4

Control, compliance and responsibility 5

Changing approaches to providing health care 5

Developing a patient‐centred approach 7

Introducing counselling skills 8

Developing a counselling approach 10

Portrait of a dietitian using a counselling approach 10

Qualities for a dietitian to develop 11

Providing care 12

Personal and professional development 12

Self‐awareness 13

Frame of reference 13

Self‐worth 13

Reflective practice 14

Benefits of reflective practice 14

Use of the word ‘reflection’ 15

Different approaches to counselling and psychotherapy 15

Psychoanalytic approach 15

Behavioural and cognitive approaches 16

Humanistic approach 16

Transactional Analysis 17

Systemic therapy 17

Neuro‐linguistic programming 17

Mindfulness 18

Overview of the evidence concerning the use of communication skills in dietetic practice 18

References 19

2 The patient 22

Using a patient‐centred approach 22

The concerns of the patient 23

The feelings of the patient 24

The expectations of the patient 25

The nature of change 26

Change has a ripple effect 26

Change occurs in a number of ways 26

People react and adapt to change in various ways 27

Change is paradoxical, in that we both want it and do not want it 27

Change can have implications of which we are not aware 27

Reactions to change 27

Shock 28

Release of emotion 28

Talking about it 28

Ambivalence 29

Bargaining 29

Doubt about being able to cope 29

Blame 30

Distancing 30

Adapting to change 30

Patient satisfaction 31

References 32

3 The relationship between dietitian and patient 33

Circumstances surrounding the dietitian’s relationship with the patient 33

Core conditions for a helping relationship 34

Empathy 34

Acceptance 37

Genuineness 39

Issues arising between patient and dietitian: power, dependency, transference and counter‐transference 40

Power 40

Dependency 41

Transference and counter‐transference 41

The working alliance 42

A therapeutic bond 42

Goals 43

Tasks 43

Further points to consider 44

References 44

4 Aspects of the helping process 45

The dietitian’s concerns 46

Keeping boundaries: how the dietitian can manage time, confidentiality and referral 46

Establishing a time boundary 47

Maintaining confidentiality 47

Recognising professional and personal limitations: when, how and where to make a referral 50

Recognising the different developmental stages of the helping process 51

Stage 1: Listening to the patient’s story 51

Stage 2: Clarifying what the patient wants 52

Stage 3: Planning ways to achieve goals 54

Looking at the psychological process of change 55

Putting it into practice 55

Coping with ambivalence 57

Incorporating systemic awareness 58

Examples of questions to ask about diet and the home situation 59

How to end 59

Support for the dietitian 61

References 61

5 Conducting a structured interview 62

A framework for the interview 62

Beginnings 63

The interview setting 63

Preparing to provide a helping relationship 64

Opening the interview 65

Forming first impressions 65

Making introductions 68

Finding a starting point 68

Middles 69

Setting the agenda 69

Assessing motivation 71

Making a contract 72

Taking a diet history 73

Giving dietary advice 75

Monitoring the relationship 79

Endings 81

Acknowledging the ending 81

Summarising what has taken place 81

What next? 82

Saying goodbye 82

After the interview 83

References 84

Part 2: The skills 85

6 Active listening 87

The process of listening 87

Attending: a way of demonstrating acceptance 88

Attending is giving someone our attention as fully as we can 88

A listener who conveys acceptance is someone who is safe to talk to 89

Barriers to attending 90

Eye contact 90

Environment 90

Events and emotions 90

Echoes within 91

Attending to non‐verbal communication 91

Voice 91

Eye contact 92

Facial expression 92

Appearance 93

Posture 93

Gesture 93

Discrepancies and incongruities 93

Developing powers of observation 94

Distinguishing between observation and interpretation 94

Managing silences 95

Mirroring 96

Touching 97

References 98

7 Ways of responding 99

The effects of responding 99

Types of response 100

Low‐risk responses 101

Moderate‐risk responses 101

High‐risk responses 101

Very high‐risk responses 103

Self‐disclosure 103

The purpose behind a response 104

The power of language 105

Use of ‘we’, ‘you’ and ‘I’ 105

Language of success or failure 106

Language of doubt 106

Language of negativity 106

Reflective responding 107

The technique of reflecting 108

The skill of reflecting 109

Focusing on feelings 111

Mirroring language 112

When to use reflective responding 113

When reflective responding is not helpful 113

References 114

8 Making helpful interventions 115

Moving towards a helping conversation 115

Helpful interventions 116

Examining attitudes 117

Providing the core conditions when making a helpful intervention 118

Timing and level of intervention 119

Ways to intervene 121

Asking questions 121

Open questions 122

Closed questions 123

Highlighting paradoxes, discrepancies and inconsistencies 123

Confronting absolutes 123

Choosing a focus 124

Addressing sensitive issues 125

When the dietitian does not believe the patient 125

Helping someone towards clearer thinking using CBT 126

Recognising thoughts and distinguishing them from feelings 126

‘What’s going through your mind when you think that?’ 126

References 130

9 Conveying a clear message: assertiveness in action 131

Counselling skills and assertiveness 131

What is assertive communication? 132

Developing assertiveness 132

Self‐awareness and assertiveness 132

Self‐esteem and assertiveness 133

Communicating feelings 133

Aggression 133

Passivity 134

Manipulation 134

Advantages and disadvantages of assertiveness 134

Advantages 134

Disadvantages 135

Delivering a clear message 135

Preparation and reflection 135

Rehearsal 135

Delivery 135

Examples of assertiveness skills in practice 136

With a patient 136

With a GP practice manager 137

Confronting difficult situations 138

Confrontation from a colleague 139

Confrontation from a patient 139

Confronting a patient 140

Confronting a colleague 141

Handling criticism and praise 142

Criticism 142

Praise 144

Support with handling criticism and praise 145

Dealing with aggressive behaviour 145

Assessing risks 146

Taking care of yourself 146

Defusing the situation 147

Be A DEFUSER 147

Coping with the after‐effects 148

An ABC for conveying a clear message 148

References 150

Part 3: Putting skills into practice: further considerations 151

10 Working with more than one person 153

When others are in the room 153

Reasons for others to be present 153

Context of the interview 154

Risks and benefits of involving another person 154

Issues to consider when others are present 155

Dynamics between those present 155

Agendas of those present 156

Relationships between those present 156

Language and culture of those present 157

Maintaining equity and creating structure and boundaries 158

Maintaining equity 158

Creating structure and boundaries 159

Family meetings 159

Example 160

Who is responsible for finding a solution? 161

Who is leading the consultation? 161

Group work 162

Group size 162

Group demographics 162

Group dynamics 162

Group process 163

Using counselling skills with a group 164

References 165

11 Coping with loss and bereavement 166

How loss concerns dietitians 166

The need to grieve 168

Our reactions to grief 168

The process of grieving 168

How the dietitian can help 169

Loss of weight: a loss or a gain? 171

Loss of self‐esteem 171

Loss of health: living under threat of death 172

Loss of appetite 173

Support for the patient and the dietitian 174

References 175

12 Developing cultural awareness 176

What is culture? 176

Cultural changes within dietetics and the NHS 177

Move away from tradition and hierarchy 177

Prevention of disease and the rise of nutrition 178

Growth of the profession and an increase in diversity 178

Introducing a patient‐centred approach 179

Evidence‐based practice and CPD 179

Stress from change and limited resources 180

Developing cultural awareness 180

Prejudice and its development 181

Attitudes and expectations 182

Effect of prejudice on the helping relationship 182

Towards more effective communication 183

Example 183

Making introductions and establishing credentials 183

Language 184

Boundaries and goal setting 185

Social rituals and customs 186

Making effective use of an interpreter 186

Who is the interpreter? 186

Preparing for the interview 187

Working with an asylum seeker 188

Coping with difficulties 188

Ways of building bridges 188

References 189

13 Working with parents and children 190

Challenges for the dietitian 190

The needs of the child 191

Meeting the family 192

Background 192

Interview 192

Reflections 193

Considerations 193

Making a plan 194

Next meeting 194

Summary of how Sue worked with Peter 195

When a child withdraws 195

Guidelines for handling this situation 196

The angry child 196

Guidelines for handling this situation 196

The well‐behaved child 197

Guidelines for handling this situation 197

Overprotective parents 197

Guidelines for handling this situation 198

Aggressive parents 198

Guidelines for handling this situation 198

The absent parent 198

Guidelines for handling this situation 199

The dying child 199

Guidelines for handling this situation 199

Reference 200

14 Working with difficulties in physical and mental health 201

Minority needs as part of society 201

Effect on patient and dietitian 202

The patient 202

The dietitian 203

Resources for the dietitian to develop 203

Internal resources 203

External resources 204

Physical difficulties 204

Hearing 205

Sight 205

Speech 206

Mobility and movement 207

Appearance 207

Invisible disabilities 208

Mental health 208

Recognising anxiety and depression 208

How the dietitian can help 209

Helping those with eating distress: disordered eating and eating disorders 211

Hearing suicidal thoughts: how can I bear it? 217

Maintaining confidentiality when making a referral 218

References 219

Part 4: Areas for personal and professional development 221

15 Developing self‐awareness 223

Why self‐awareness is important 223

Ways to develop self‐awareness 224

Time for ourselves 224

Becoming more mindful 224

Self‐esteem 225

Ways to build self‐esteem 226

Acknowledgement 226

Tips for building self‐esteem 227

Coping with stress 227

Ways to unwind 229

Keeping a reflective diary 231

References 231

16 Giving and receiving support 233

When support is needed 233

Knowing your limits 234

Supporting yourself 235

Reflecting on practice 235

Creating a dialogue 235

Building a support network 236

Asking for support 237

Tips for asking for support 237

Giving support 238

Tips for giving support 239

Giving constructive support 239

Support from training, assessment and monitoring 240

Training in communication skills 241

Training in counselling skills 242

Supportive peer discussion 243

Making arrangements 243

Managing the session 243

Supervision 244

Personal counselling 244

What does counselling involve? 245

Who seeks counselling? 246

References 247

Index 248