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 xivAbout the authors xviPreface to the third edition xviiAcknowledgements xxIntroduction xxiAbout the companion website xxvPart 1: Using a counselling approach in patient‐centred practice 11 The dietitian 3The role of the dietitian 3Using a prescriptive approach 4Control, compliance and responsibility 5Changing approaches to providing health care 5Developing a patient‐centred approach 7Introducing counselling skills 8Developing a counselling approach 10Portrait of a dietitian using a counselling approach 10Qualities for a dietitian to develop 11Providing care 12Personal and professional development 12Self‐awareness 13Frame of reference 13Self‐worth 13Reflective practice 14Benefits of reflective practice 14Use of the word ‘reflection’ 15Different approaches to counselling and psychotherapy 15Psychoanalytic approach 15Behavioural and cognitive approaches 16Humanistic approach 16Transactional Analysis 17Systemic therapy 17Neuro‐linguistic programming 17Mindfulness 18Overview of the evidence concerning the use of communication skills in dietetic practice 18References 192 The patient 22Using a patient‐centred approach 22The concerns of the patient 23The feelings of the patient 24The expectations of the patient 25The nature of change 26Change has a ripple effect 26Change occurs in a number of ways 26People react and adapt to change in various ways 27Change is paradoxical, in that we both want it and do not want it 27Change can have implications of which we are not aware 27Reactions to change 27Shock 28Release of emotion 28Talking about it 28Ambivalence 29Bargaining 29Doubt about being able to cope 29Blame 30Distancing 30Adapting to change 30Patient satisfaction 31References 323 The relationship between dietitian and patient 33Circumstances surrounding the dietitian’s relationship with the patient 33Core conditions for a helping relationship 34Empathy 34Acceptance 37Genuineness 39Issues arising between patient and dietitian: power, dependency, transference and counter‐transference 40Power 40Dependency 41Transference and counter‐transference 41The working alliance 42A therapeutic bond 42Goals 43Tasks 43Further points to consider 44References 444 Aspects of the helping process 45The dietitian’s concerns 46Keeping boundaries: how the dietitian can manage time, confidentiality and referral 46Establishing a time boundary 47Maintaining confidentiality 47Recognising professional and personal limitations: when, how and where to make a referral 50Recognising the different developmental stages of the helping process 51Stage 1: Listening to the patient’s story 51Stage 2: Clarifying what the patient wants 52Stage 3: Planning ways to achieve goals 54Looking at the psychological process of change 55Putting it into practice 55Coping with ambivalence 57Incorporating systemic awareness 58Examples of questions to ask about diet and the home situation 59How to end 59Support for the dietitian 61References 615 Conducting a structured interview 62A framework for the interview 62Beginnings 63The interview setting 63Preparing to provide a helping relationship 64Opening the interview 65Forming first impressions 65Making introductions 68Finding a starting point 68Middles 69Setting the agenda 69Assessing motivation 71Making a contract 72Taking a diet history 73Giving dietary advice 75Monitoring the relationship 79Endings 81Acknowledging the ending 81Summarising what has taken place 81What next? 82Saying goodbye 82After the interview 83References 84Part 2: The skills 856 Active listening 87The process of listening 87Attending: a way of demonstrating acceptance 88Attending is giving someone our attention as fully as we can 88A listener who conveys acceptance is someone who is safe to talk to 89Barriers to attending 90Eye contact 90Environment 90Events and emotions 90Echoes within 91Attending to non‐verbal communication 91Voice 91Eye contact 92Facial expression 92Appearance 93Posture 93Gesture 93Discrepancies and incongruities 93Developing powers of observation 94Distinguishing between observation and interpretation 94Managing silences 95Mirroring 96Touching 97References 987 Ways of responding 99The effects of responding 99Types of response 100Low‐risk responses 101Moderate‐risk responses 101High‐risk responses 101Very high‐risk responses 103Self‐disclosure 103The purpose behind a response 104The power of language 105Use of ‘we’, ‘you’ and ‘I’ 105Language of success or failure 106Language of doubt 106Language of negativity 106Reflective responding 107The technique of reflecting 108The skill of reflecting 109Focusing on feelings 111Mirroring language 112When to use reflective responding 113When reflective responding is not helpful 113References 1148 Making helpful interventions 115Moving towards a helping conversation 115Helpful interventions 116Examining attitudes 117Providing the core conditions when making a helpful intervention 118Timing and level of intervention 119Ways to intervene 121Asking questions 121Open questions 122Closed questions 123Highlighting paradoxes, discrepancies and inconsistencies 123Confronting absolutes 123Choosing a focus 124Addressing sensitive issues 125When the dietitian does not believe the patient 125Helping someone towards clearer thinking using CBT 126Recognising thoughts and distinguishing them from feelings 126‘What’s going through your mind when you think that?’ 126References 1309 Conveying a clear message: assertiveness in action 131Counselling skills and assertiveness 131What is assertive communication? 132Developing assertiveness 132Self‐awareness and assertiveness 132Self‐esteem and assertiveness 133Communicating feelings 133Aggression 133Passivity 134Manipulation 134Advantages and disadvantages of assertiveness 134Advantages 134Disadvantages 135Delivering a clear message 135Preparation and reflection 135Rehearsal 135Delivery 135Examples of assertiveness skills in practice 136With a patient 136With a GP practice manager 137Confronting difficult situations 138Confrontation from a colleague 139Confrontation from a patient 139Confronting a patient 140Confronting a colleague 141Handling criticism and praise 142Criticism 142Praise 144Support with handling criticism and praise 145Dealing with aggressive behaviour 145Assessing risks 146Taking care of yourself 146Defusing the situation 147Be A DEFUSER 147Coping with the after‐effects 148An ABC for conveying a clear message 148References 150Part 3: Putting skills into practice: further considerations 15110 Working with more than one person 153When others are in the room 153Reasons for others to be present 153Context of the interview 154Risks and benefits of involving another person 154Issues to consider when others are present 155Dynamics between those present 155Agendas of those present 156Relationships between those present 156Language and culture of those present 157Maintaining equity and creating structure and boundaries 158Maintaining equity 158Creating structure and boundaries 159Family meetings 159Example 160Who is responsible for finding a solution? 161Who is leading the consultation? 161Group work 162Group size 162Group demographics 162Group dynamics 162Group process 163Using counselling skills with a group 164References 16511 Coping with loss and bereavement 166How loss concerns dietitians 166The need to grieve 168Our reactions to grief 168The process of grieving 168How the dietitian can help 169Loss of weight: a loss or a gain? 171Loss of self‐esteem 171Loss of health: living under threat of death 172Loss of appetite 173Support for the patient and the dietitian 174References 17512 Developing cultural awareness 176What is culture? 176Cultural changes within dietetics and the NHS 177Move away from tradition and hierarchy 177Prevention of disease and the rise of nutrition 178Growth of the profession and an increase in diversity 178Introducing a patient‐centred approach 179Evidence‐based practice and CPD 179Stress from change and limited resources 180Developing cultural awareness 180Prejudice and its development 181Attitudes and expectations 182Effect of prejudice on the helping relationship 182Towards more effective communication 183Example 183Making introductions and establishing credentials 183Language 184Boundaries and goal setting 185Social rituals and customs 186Making effective use of an interpreter 186Who is the interpreter? 186Preparing for the interview 187Working with an asylum seeker 188Coping with difficulties 188Ways of building bridges 188References 18913 Working with parents and children 190Challenges for the dietitian 190The needs of the child 191Meeting the family 192Background 192Interview 192Reflections 193Considerations 193Making a plan 194Next meeting 194Summary of how Sue worked with Peter 195When a child withdraws 195Guidelines for handling this situation 196The angry child 196Guidelines for handling this situation 196The well‐behaved child 197Guidelines for handling this situation 197Overprotective parents 197Guidelines for handling this situation 198Aggressive parents 198Guidelines for handling this situation 198The absent parent 198Guidelines for handling this situation 199The dying child 199Guidelines for handling this situation 199Reference 20014 Working with difficulties in physical and mental health 201Minority needs as part of society 201Effect on patient and dietitian 202The patient 202The dietitian 203Resources for the dietitian to develop 203Internal resources 203External resources 204Physical difficulties 204Hearing 205Sight 205Speech 206Mobility and movement 207Appearance 207Invisible disabilities 208Mental health 208Recognising anxiety and depression 208How the dietitian can help 209Helping those with eating distress: disordered eating and eating disorders 211Hearing suicidal thoughts: how can I bear it? 217Maintaining confidentiality when making a referral 218References 219Part 4: Areas for personal and professional development 22115 Developing self‐awareness 223Why self‐awareness is important 223Ways to develop self‐awareness 224Time for ourselves 224Becoming more mindful 224Self‐esteem 225Ways to build self‐esteem 226Acknowledgement 226Tips for building self‐esteem 227Coping with stress 227Ways to unwind 229Keeping a reflective diary 231References 23116 Giving and receiving support 233When support is needed 233Knowing your limits 234Supporting yourself 235Reflecting on practice 235Creating a dialogue 235Building a support network 236Asking for support 237Tips for asking for support 237Giving support 238Tips for giving support 239Giving constructive support 239Support from training, assessment and monitoring 240Training in communication skills 241Training in counselling skills 242Supportive peer discussion 243Making arrangements 243Managing the session 243Supervision 244Personal counselling 244What does counselling involve? 245Who seeks counselling? 246References 247Index 248