NUTR 4363 Counseling Exam 1 Study Guide PDF

**NUTR 4363 Counseling Exam 1 Study Guide** **[Chapter 1: Preparing to Meet Your Clients]** 1. **Define nutrition education and nutrition counseling, and how are they different?** - **Nutrition education** = learning experiences aimed to promote voluntary adoption of health-pro...

**NUTR 4363 Counseling Exam 1 Study Guide** **[Chapter 1: Preparing to Meet Your Clients]** 1. **Define nutrition education and nutrition counseling, and how are they different?** - **Nutrition education** = learning experiences aimed to promote voluntary adoption of health-promoting dietary behaviors - = "any combination of educational strategies, accompanied by environmental supports, designed to facilitate voluntary adoption of food choices and other food- and nutrition-related behaviors conducive to health and well-being" - **Nutrition counseling** = a supportive process guiding a client toward nutritional well-being - = "a supportive process, characterized by a collaborative counselor-patient/client relationship to establish food, nutrition, and physical activity priorities, goals, and individualized action plans that acknowledge and foster responsibility for the process of guiding a client toward a healthy nutritional lifestyle by meeting nutritional needs and solving problems that are barriers to change" - Working collaboratively with someone to change a behavior - Main difference: Dissemination of information vs. a truly collaborative process 2. **List several influences listed in the chapter that affect food choices.** - Sensory Appeal -- **taste** & food preferences - The most important determinant of food choices - **Cost** - Convenience & time - Food availability & variety - Well-being - Self-expression - Convenience - Time - Preferences - Culture & religion - Psychological needs - Social needs - Social network of fiends and family - Education, occupation, and income - Media, social media, food marketing - Health and nutrition concerns, knowledge, and beliefs - Lifestyle & habits 3. **List several qualities considered most influential in the counseling relationship. KNOW!** - **Self-aware**: know their own beliefs, know why they want to be a "helper" - **Solid foundation of knowledge**: biological, social sciences, culinary arts; maintain evidence-based knowledge over time - **Ethical integrity**: dignity and worth of all people - Congruence: verbal and nonverbal actions match (facial expressions matches words) - Can **communicate** clearly - **Gender and cultural awareness** - Sense of **humor** - **Honest & genuine** - **Flexible**: not expecting perfection or have unrealistic expectations - **Optimistic & hopeful**: be their \#1 cheerleader from day 1 - **Respect, values, care, and trust others** - **Empathetic**: accurately understand what people feed from their frame of reference 4. **Describe functions of cultural values.** - **Cultural values** = "the principles or standards that members of a cultural group share in common" - Need to understand the role of these values to develop cultural sensitivity better word: cultural humility - Awareness can help prevent your personal bias, values, or problems from interfering with your ability to work with clients who are culturally different from you - Step 1 is recognizing that every single person is coming from a different space and that we are all different -- making sure you have that ability to understand, connect, and have an open mind - Cultural values function to... - **Provide** a set of rules by which to govern lives - **Serve** as a basis for attitudes, beliefs, and behaviors - **Guide** actions and decisions - **Give** direction to lives and help solve common problems - **Influence** how to perceive and react to others - **Help** determine basic attitudes regarding personal, social, and philosophical issues - **Reflect** a person's identify and provide a basis for self-evaluation 5. **Describe/list the two phases of the helping relationship.** - **(Phase 1) Build a relationship**. - Develop rapport -- show empathy and began building trust - Foundation to your relationship and ability to help your client - Goal = learn the nature of the problem from client's viewpoint, explore strengths, promote self-exploration - We want client to set their own goals, so we can tap into their personal desire to change, NOT OUR desire for them to change. - **(Phase 2) Help your client to facilitate a positive change**. - Identify specific behaviors they want to alter, and designing realistic behavior change strategies to facilitate positive action - Clients need to be open and honest (AND counselor) - Clients need to not feel criticized when difficulties occur - Nonjudgmental feedback - The relationship between you and your client is going to influence how effective you will be at facilitating positive action for change. **[Chapter 2: Frameworks for Understanding and Attaining Behavior Change]** 6. **Define concept/construct, model, and theory.** - **Concepts** = the building blocks or major components of a theory - **Constructs** = concepts that are used in a theory or model - **Model** = relates events, objects, and principles together without explaining the reasons (generalized descriptions) - Explains "how" things work, but not the "why" the relationships are related - Does not attempt to provide understand of the relationship between variables - **Theory** = explains the relationships between concepts; may contain dozens of concepts and principles organized in such a way that it explains an event or phenomenon - A set of interrelated concepts, definitions, and propositions that present a systematic view of the phenomenon with the purpose of predicting or explaining it - Tells us the "how" AND the "why" (different from a model) - Produces understanding (different from a model) 7. **Define self-efficacy.** - **Self-efficacy** = an individual's confidence to perform a specific behavior - Belief in ability to make change - Positive self-efficacy increases probability of making a change. - A person's confidence in their ability to accomplish a behavior change might be more important than actual skill. 8. **Label, list and describe [all] the constructs of the health belief model.** \[Exercise 2.1 for examples\] - **[Health Belief Model]** proposes that cognitive factors influence an individual's decision to make and maintain a specific health behavior change. - **Perceived susceptibility** = client perceives personal susceptibility to a disease/condition - Ex: personal belief in the chances of developing IBS - **Perceived severity** = client perceives the disease or condition as having some degree of severity, such as physical or social consequences - Ex: perception that a leaky gut can negatively affect a person's work productivity - **Perceived benefits** = client believes that there are particular benefits in taking actions that would effectively prevent or cure the disease/condition - Ex: perception that eating fruits and veggies may lower risk of inflammation - **Perceived barriers** = client perceives no major barrier that would impede the health action - Ex: perception that eating healthfully will be costly and inconvenient - **Cues to action** = client is exposed to a cue to take action - Ex: reading a blog about gut microbiota prompts action in eating fiber-rich foods - **Self-efficacy** = client has confidence in personal ability to perform the specific behavior - Ex: individual's confidence in ability to prepare a meal with whole grains +-----------------------+-----------------------+-----------------------+ | **Health Belief Model | **Sample Client | **Intervention | | Constructs** | Statement** | Possibility** \[Table | | | | 2.2\] | +=======================+=======================+=======================+ | Perceived | "I worry about my | Educate on disease | | Susceptibility | chances of developing | risk and link to | | | blood pressure." | diet. Compare to an | | | | established standard. | | | | | | | | "The AHA recommends | | | | keeping BP below | | | | 120/80. Your BP is | | | | 148/110." | +-----------------------+-----------------------+-----------------------+ | Perceived Severity | "Well, I have high | Discuss disease | | | blood pressure, but I | impact on client's | | | feel fine." | physical, economic, | | | | social, and family | | | | life. Show graphs and | | | | give statistics. | | | | Clarify consequences. | | | | | | | | "High BP increases | | | | risk of developing a | | | | stroke." | +-----------------------+-----------------------+-----------------------+ | Perceived Benefits | "Eating more salads | Provide role models | | | would be good for my | and testimonials. | | | health." | Imagine the future. | | | | Specify action and | | | | benefits of the | | | | action. | | | | | | | | "Eating more plant | | | | foods can be good for | | | | lowering your BP." | +-----------------------+-----------------------+-----------------------+ | Perceived Barriers | "The foods I need to | Explore strategies to | | | eat to lower my blood | overcome barriers | | | pressure are | such as | | | tasteless." | inconvenience, cost, | | | | and unpleasant | | | | feelings. Offer | | | | incentives, | | | | assistance and | | | | reassurance. Correct | | | | misinformation and | | | | misperceptions. | | | | Provide taste tests. | | | | | | | | "There are good | | | | recipes to try using | | | | various herbs and | | | | salt substitutes." | +-----------------------+-----------------------+-----------------------+ | Cues to action | "My roommate always | Link current symptoms | | | has savory snacks and | to health problem, | | | potato chips on the | discuss media to | | | counter." | promote health | | | | action, encourage | | | | social support, use | | | | reminder systems | | | | (sticky notes, | | | | automated cell phone | | | | messages, mailings). | | | | | | | | "You could place | | | | additional snacks and | | | | nuts on the counter | | | | that are low in | | | | sodium." | +-----------------------+-----------------------+-----------------------+ | Self-efficacy | "I am confident that | Provide skill | | | I can prepare low | training and | | | sodium pasta dishes." | demonstrate behaviors | | | | step-by-step. | | | | Encourage goal | | | | setting and positive | | | | reinforcement. | | | | | | | | \"Yes, you are on the | | | | right track." | +-----------------------+-----------------------+-----------------------+ 9. **Label, list the stages of change in the Transtheoretical Model of Change (TTM), and describe each stage.** - **Transtheoretical Model of Change (TTM)** = readiness to change; explains how behavior change occurs - Behavior change is a process that occurs over time; is NOT linear +-----------------------+-----------------------+-----------------------+ | **TTM Stage** | **Describe** | **Intervention | | | | Strategies** | +=======================+=======================+=======================+ | **Precontemplation** | No intention of | \- Increase | | | changing within the | information and | | | next 6 months | awareness | | | | | | | \- Resist any efforts | \- Ask: "What can I | | | to modify the | do to help? Does | | | behavior | anyone in your family | | | | have this problem? | | | \- Reasons: not aware | How would you feel | | | a problem exists, | about making a | | | denial, aware but | change?" | | | unwilling to change, | | | | feeling hopelessness | | | | after attempting to | | | | change | | +-----------------------+-----------------------+-----------------------+ | **Contemplation** | Aware of problem; | \- Encourage | | \[Ambivalence\] | thinking about | self-reevaluation | | | changing behavior | | | | within the next 6 | \- Increase | | | months | confidence in ability | | | | to adopt recommended | | | \- Ambivalence: | behaviors | | | alternating between | | | | reasons to change and | \- Discuss and | | | not to change | resolve barriers to | | | | change | | | \- May stay in this | | | | stage for years | \- Encourage support | | | | networks | | | \- May make | | | | statements that | \- Give positive | | | contradict each other | feedback about their | | | | abilities | | | \- Perceived | | | | barriers: | \- Help clarify | | | unacceptable tastes, | ambivalence about | | | economic constraints, | adopting behaviors | | | inconvenience | and emphasize | | | | expected benefits | | | | | | | | \- Ask: "What changes | | | | have you been | | | | thinking about? What | | | | are the pros and | | | | cons? How do you feel | | | | about it? What would | | | | make it easier or | | | | harder? What would be | | | | the results of the | | | | change? How can I | | | | help?" | +-----------------------+-----------------------+-----------------------+ | **Preparation** | \- Believe the | \- Resolution of | | | advantages outweigh | ambivalence | | | the disadvantages | | | | | \- Firm commitment | | | \- Committed to take | | | | action in the near | \- Development of a | | | future, usually 30 | specific action plan | | | days | | | | | \- Encourage client | | | \- May already have | to set specific, | | | taken small | achievable goals | | | steps/made small | (SMART goals) | | | changes | | | | | \- Remove cues for | | | | undesirable behavior | | | | | | | | \- Reinforce small | | | | changes they may | | | | already be doing. | | | | | | | | \- Encourage client | | | | to make the intent to | | | | change public (gives | | | | client | | | | accountability) | | | | | | | | \- Ask: "When are you | | | | intending to make | | | | changes? How will you | | | | do it? What changes | | | | have you made | | | | already? How will | | | | your life improve?" | +-----------------------+-----------------------+-----------------------+ | **Action** | \- Altered the target | \- Collaborate on | | | behavior to an | tailored plans | | \[Making changes\] | acceptable degree for | | | | 1 day or up to 6 | \- Behavioral skills | | | months | training | | | | | | | \- Continue to work | \- Cultivate social | | | on concern/change | support | | | | | | | \- Do not view new | \- Develop or refer | | | behaviors as | to education program | | | permanent | to include | | | | self-management | | | \- Relapse most | skills. | | | common to occur in | | | | the first 3-4 months | \- Consider reward | | | | possibilities. | | | | | | | | \- Remove cues for | | | | undesirable behaviors | | | | and add cues for | | | | desirable ones. | | | | | | | | \- Set realistic | | | | goals. | | | | | | | | \- Ask: "What are you | | | | doing differently? | | | | What problems are you | | | | having? Who can help | | | | you? How can I help? | | | | What do you do | | | | instead of \_\_\_?" | +-----------------------+-----------------------+-----------------------+ | **Maintenance** | Engaged in the new | \- Relapse prevention | | | behavior for more | | | | than 6 months | \- Collaborative, | | | | tailored revisions, | | | \- May need to work | problem solving | | | actively to modify | skills, and social & | | | the environment to | environmental support | | | prevent relapse | | | | | \- Collect info about | | | | local resources | | | | (support groups, | | | | shopping guides). | | | | | | | | \- Encourage them to | | | | come back to your if | | | | lapse/relapse occurs. | | | | | | | | \- Recommend more | | | | challenging changes | | | | if they are highly | | | | motivated. | | | | | | | | \- Ask: "How do you | | | | handle times when you | | | | slip up? What | | | | obstacles are you | | | | facing? What are your | | | | future plans? What | | | | issues have you | | | | solved?" | +-----------------------+-----------------------+-----------------------+ 10. **Describe the theory of planned behavior, social cognitive theory, client-centered counseling, cognitive-behavioral therapy, and solution-focused therapy.** - **Theory of planned behavior** = an individual's health behavior is directly influenced by the intention to engage in that behavior - **Social cognitive theory** = provides a basis for understanding and predicting behavior, explaining the process of learning, and designing behavior change interventions. - There is a dynamic interaction of personal factors, behavior, and the environment, with a change in one factor capable of influencing the others (known as reciprocal determinism). - People and their environment interact continuously, each influencing the other - Self-efficacy - Knowledge and skills needed, and required - Learning occurs through taking action, observations or modeling of others taking action, evaluation of the results of those actions - **Client-centered counseling** = believes humans are basically rational, socialized, and realistic with a tendency toward self-growth, self-actualization, and self-direction - **Counselor:** - Counselors help develop environment by accepting clients without passing judgement on their thoughts, behavior, or physique - Respect clients regardless of compliance to medical and counseling advice  - **Client: ** - Actively participate in clarifying needs and exploring potential solutions - Realize their potential  growth in and environment of unconditional  positive self-regard - Discover within themselves the capacity to use the relationship to change and grow, thereby promoting wellness and independence  - **Cognitive-behavioral therapy** = focuses on changing the environment or internal factors so that it will be conducive to learning new behaviors - Combines **cognitive therapy and** **behavioral therapy** - Behavioral: many behaviors are learned, so it is possible to learn new behaviors - 3 basic approaches for behavior modification: - \(1) Classical conditioning: focuses on antecedents - Stimuli, cues, smelling/seeing food = stimulus to eat (a candy bowl by desk) - \(2) Operant conditioning: law of effect which means behaviors can change by positive or negative effect - What rewards and consequences occur due to that behavior - \(3) Modeling: observational learning and success stories - Video, demos - **Solution--focused therapy** = focus on times of success & aim for clients to use solution-oriented language - Have clients concentrate on solutions that have worked for them in the past. - Identify strengths to be expanded upon. - Make a list of resources. - Investigate accomplishments -- no matter how small, adaptive strategies are likely to emerge. - Focus on helping replicate and expand on those skills. 11. **Define theory of planned behavior and define the 3 factors affecting behavior intentions.** - **[Theory of planned behavior]** = an individual's health behavior is directly influenced by the intention to engage in that behavior - Factors that affect behavioral intentions: attitudes, subjective norms, perceived behavioral control - **Subjective norms** = perceived social pressure reflects beliefs about whether significant others' approve or disapprove of the behavior; determined by normative beliefs and motivation to comply - Normative beliefs -- the strength of our beliefs that significant people approve or disapprove of the behavior - Motivation to comply -- strength of our desire to comply with the opinion of significant others - **Perceived behavioral control** = overall measure of an individual's perceived control over the behavior - Control beliefs -- influenced by presence or absence of resources supporting or impeding behavioral performance - Control factors -- internal factors, i.e. social or physical environmental factors - **Attitudes** = favorable or unfavorable evaluations about a given behavior b - Outcome beliefs = beliefs about outcomes of our action - Evaluations of outcomes = how important these outcomes are to the client 12. **Be able to [write out] the definition of MI, decrease what? While increasing what?** - **[Motivational Interviewing (MI)]** = helps clients to resolve their ambivalence to change by increasing discrepancy between their current behaviors and desired goals while decreasing resistance to change. - Integrates client-centered counseling and the TTM - Collaborative approach - **Ambivalence** = mixed feelings/uncertainty about something - **Discrepancy** = highlight the gap between a person's current situation and their desired goals or values - Awareness between present behavior and important goals facilitates change. - Objective is to amplify discrepancy until it overrides the need to keep the present behavior. - Encourages clients to clarify: - Important goals - Vocalize reasons to change - Explore consequences of their present discrepancy assists them in making a decision to change - Ask: "Tell me some of the good things and less good things about your behavior/concern." "What will you life look like 5 years from now if you don't make changes and continue your current behavior?" 13. **Label, list and describe the constructs of MI - OARS, and RULE in detail what they each mean.** - RULE: 4 guiding principles of MI - R = Resist the righting reflex. - U = Understand and explore motivations. - L = Listen with empathy. - E = Empower the client. +-----------------------------------+-----------------------------------+ | **"RULE" Principle** | **Describe** | +===================================+===================================+ | **R = Resist the righting | \- Resistance is normal. | | reflex.** | | | | \- Don't provide all the reasons | | | for changing. | | | | | | \- More arguments on your part = | | | more resistance and defensive | | | behaviors | | | | | | \- Encourage the client to assume | | | control. | | | | | | \- Ask for clarifications or | | | elaborations. "Please explain a | | | little more about that." | +-----------------------------------+-----------------------------------+ | **U = Understand and explore | \- Explore perceptions and see a | | motivations.** | discrepancy regarding their | | | current behavior compared to | | | their values, beliefs, & | | | concerns. | | | | | | \- Guide the conservation to | | | encourage them. How? Use change | | | talk; clarify important goals; | | | vocalize reasons to change; | | | explore potential consequences of | | | current behavior | | | | | | \- When the discrepancy | | | overwhelms the need to keep the | | | present behavior, client will | | | likely make a decision to change. | +-----------------------------------+-----------------------------------+ | **L = Listen with empathy.** | \- "You are okay." | | | | | | \- Clients need to feel safe to | | | reveal discrepancy. | | | | | | \- Acceptance facilitates change. | | | | | | \- Acceptance and understanding | | | of their perspective | | | | | | \- "I understand change is | | | difficult." | | | | | | \- "It is okay to struggle with | | | change." | +-----------------------------------+-----------------------------------+ | **E = Empower the client.** | \- Belief in the ability to | | | change is an important motivator. | | | | | | \- Stress importance that they | | | are the ones to carry out the | | | change. | | | | | | \- Indicates that you believe | | | they can make the change, which | | | can increase their self-efficacy | +-----------------------------------+-----------------------------------+ - OARS: interviewing/counseling techniques - O = Open-ended questions - A = Affirmations - R = Reflective listening - S = Summaries +-----------------------------------+-----------------------------------+ | **"OARS" Techniques** | Describe | +===================================+===================================+ | **O = Open-ended questions** | \- Communicate curiosity, | | | concern, and respect. | | | | | | \- Ask about pros and cons | | | | | | \- What worries them the most | | | | | | \- Have them envision their | | | future | | | | | | \- Ask about priorities in life, | | | then ask how the change fits into | | | their hierarchy. | +-----------------------------------+-----------------------------------+ | A = Affirmations | \- Recognize their strengths and | | | efforts | +-----------------------------------+-----------------------------------+ | R = Reflective listening | \- Interpret the heart of the | | | client's message and reflect the | | | interpretation back to them. | | | | | | \- Encourages them to keep | | | talking. | | | | | | \- You need to decide what to | | | reflect back and what to ignore. | +-----------------------------------+-----------------------------------+ | S = Summaries | \- Done periodically throughout | | | session | | | | | | \- Helps organize thoughts | | | | | | \- Reinforces change talk | | | | | | \- Clarify discrepancies or | | | transition to a new topic. | | | | | | \- Helps make sure you're both on | | | the same page. | +-----------------------------------+-----------------------------------+ 14. **Describe the 3 ways to utilize the 1-10 scale. Describe how to use the scale when working with a client.** - Ask client to rate the importance of the behavior change. - Ask client to rate their confidence in making the change. - Ask client to rate their readiness to start making the change. - Ask them to explain/elaborate on why they didn't choose a higher or lower number. - Use when trying to **evoke change talk**. (U in RULE: "Understand and explore motivations.") **[Chapter 9: Section 9.8 Lifespan Communication & Intervention Essentials]** 15. **Define the age categories.** - Preschool-aged children: 2-5 y/o - Middle childhood: 6-11 y/o - Adolescence: 12-19 y/o (3 groups -- early, middle, and late adolescence) - Adults 20-64 y/o - Older adults: 65+ y/o 16. **For each age category understand and describe: [determinants] of food behavior, [developmental] factors, [nutritional risks], and [intervention] strategies.** - See Table on last page. **[Chapter 3: Communication Essentials]** 17. Describe the stages of skill development in nutrition counseling. - \(1) Motivation - Must have the desire to learn - Helps to have a supporting environment - Find a mentor and learn from them. - Practice! - \(2) Learning - Acquire knowledge, skills, and attitude - Be a lifelong learner: - Read & observe - Participate in learning activities & attend workshops, presentations - Engage in discussions - \(3) Awkwardness -- expect it! - Role-play various situations. - Find friends that would like counseling to practice. - \(4) Conscious awareness - Know that as you gain skill, you will still be consciously aware of the process. - \(5) Automatic response - Little or no forethought or discomfort - \(6) Proficiency -- ultimate goal - When you can perform and modify the skills w/ a variety of health conditions, in a variety of settings - Once you are more comfortable, you can experiment w/ different approaches and modify and expand your skills 18. **Describe some challenges a novice counselor might have.** - Interpreting client's statement in several ways - Encoding = the ability to express a thought - Client may have a faulty encoding process, meaning they may use generalizations, don't clearly express their thoughts, might be in denial or have anxiety - Distortions = words are not heard properly - Decoding = listener distorts the message - Mental filters = life experiences - We ALL interpret statements through mental filters created by past experiences - Cultural influences - Culture orientation has a major impact on communication. - Closer client & counselor are in sharing a common culture, the likelihood of minimal distortions and conversation will flow smoothly. - Greatest influence on cross-cultural communication: race, gender, age, nationality - Intercultural influences on communication: - Degree of acculturation or assimilation - Socioeconomic status - Health condition - Religion - Education background - Sexual orientation - Political affiliation - Miscommunication 19. **List several unproductive non-verbal behaviors.** - Toe tapping, swinging feet - Pencil tapping, twirling - Yawning - Looking at your watch or clock, shoes, papers on your desk, or anything in the room excessively - Slouching - Playing with your hair - These all give impression you are not totally focused on your client. 20. **Define synchrony.** - **Synchrony** = mirror and match your client's body language - Take your cues from your client. - Harmonize w/ their expressive state as much as possible. - Match their behaviors -- head tilting, using client's words (can help form a connection) 21. **List and describe the 4 communication roadblocks, be able to describe how the roadblocks interfere with self- exploration.** - **Communication roadblocks** are obstacles that counselors (and clients) inadvertently put up that block self-exploration. - Happens when counselors impose their own views, feelings, opinions, prejudices, and judgements - Be ware of the affect of blocking, stopping, diverting, or changing the direction of communication. - Can be used at the right time after you believe you have listened carefully and understood the client's story -- but be careful you don't just shut down the counseling session. - Types of roadblocks \[See Table 3.5\] \(1) Disagreeing \(2) Warning \(3) Agreeing: giving advise \(4) Reassuring: making suggestions 22. **Define empathy.** - **Empathy** = a true understanding of another's unique perspective and experience w/o judging, criticizing or blaming - NOT sympathy -- more than putting oneself in their shoes - Sympathy is what I feel toward you; empathy is what I feel AS YOU - Requires a shift of perspective -- it is not what you'd experience in their shoes, but is what I experience AS YOU in your shoes - Requires you to shift between my experiencing as you what you feel and my being able to think as me about your experience. - Patient needs to believe they have been accurately understood and heard -- needs to know you empathize w/ them 23. **Define [all] 16 of the counseling responses.** \[See flip assignment\] - **[\[1\] Attending]** (active listening) - Giving undivided attention - Listening for verbal messages - Observing nonverbal behavior - Focus is on what you see and hear - Eye contact - Attentive body language - Vocal style -- speech rate, volume, and tone - Verbal following -- nods, "Hmm-hmm", "Yes, I see" - Listening -- "A man has one tongue and two ears, that we may hear twice as much as we speak" - Not simply a matter of hearing words but rather hard work requiring focused attention and concentration. - Effective listening includes: - Openness: personal beliefs are set aside - Concentration: tuning out everything else - Lag time self-talk - Rehearsing rebuttals - Assumptions - assuming you know the solution - Comprehension: by attending to openness and concentration -- you will likely comprehend the meaning and importance - \*The biggest communication problem is we do not listen to understand. We listen to reply." - Active Listening Guidelines: - Remind yourself to focus and concentrate before each session - Listen for meaning, not just words - Use thinking-speaking lag time to examine and comprehend client's meaning - Avoid judgments. Be inquisitive and keep an open mind - Don't allow your mind to drift; bring focus back if you wander - Use verbal and nonverbal prompts - Maintain good eye contact if culturally appropriate - **[\[2\] Reflection]** (empathizing) - Labeling a client's expressed verbal and/or nonverbal emotion. - When a counselor has accurately sensed an emotional state and has effectively used reflection responses, clients feel understood - They feel seen and are no longer invisible, alone, strange, or unimportant - [THEN] they perceive that the counselor can help them - 4 steps in reflecting -- see Q24 - **[\[3\] Legitimation]** (affirmation, normalization) - Communicates the acceptance and validation of the client's emotional experience. - Making their situation "normal" - Counselor acknowledges that it is normal to have the reactions or feelings - Verify first that you've identified the feeling before making a legitimating statement - *"It seems to me...."* - *"I can understand..."* - **[\[4\] Respect]** - Appreciation for the worth of the client -- critical! - Explicit respect responses: - Words of appreciation on the ability to overcome adversity and adjust to difficult situations - Compliments on willingness to search for nutrition interventions - *"You have done a wonderful job of purchasing new foods to try"* - *"I'm impressed you are searching for solutions that will work for you"* - **[\[5\] Personal support]** - Lets them know strategies are available - You are there to help them implement those strategies - You want to help - *"There are a number of dietary options for you to be able to use to improve your cholesterol levels. I look forward to working with you to do that." "I am supporting you."* - **[\[6\] Partnership]** - Establish a collaborative relationship - Let them know you are going to work together to find solutions - *"I want us to work together to find and try a strategy that will work for you. After we talk about your dietary problem, and what strengths you have, we'll look at some options to consider as a solution."* - **[\[7\] Mirroring]** (parroting, echoing) - Repeat back **exactly** what the client said with few words changed - Lets them know you are listening - Encourages them to keep talking and exploring - Don't overuse (use sparingly) - **[\[8\] Paraphrasing]** (summarizing) - Rephrasing what the client said and meant - Just like mirroring - lets them know you are listening - Encourages them to continue talking - Can aid in clarifying concerns to you and themselves - If you didn't paraphrase correctly -- patient is likely to clarify - Use more periodic though the session - **\[9\] Giving feedback** (immediacy) - Telling clients what you have directly observed about their verbal and nonverbal behavior - It invites them to examine the implications and increases self-awareness - Be positive and specific - Note the behavior(s) - Do not put the client on the defensive - *"I noticed when you said you wanted to give up sodas, that you looked sad and cast your eyes downward"* - **\[10\] Questioning** - Gathers information, encourages exploration, and change the direction of a discussion - Ask appropriate questions and time them well - Only ask if there is a particular therapeutic reason in mind - Interrupts concentration, shifts conversation to the counselor's concerns - \[See Exhibit 3.1 Tried-and-True Qs\] - Open ended -- allows them to elaborate on ideas vs. closed ended questions "OARS" - Start with "**what** or **how**" - Funneling questions -- start out with broad topic and narrow down to specifics - Asking "Why?" is problematic -- judgmental, defensive, seem to require an excuse - Try not to use *double questions* or *question-answer traps,* or 3 questions in a row - **\[11\] Clarifying** (probing, prompting) - Encourages clients to continue talking about their concerns in order to be clear about feelings and experiences - Great to clarify throughout session make sure both on same page - *"Tell me more" "go on"* - *"Can you explain that to me in a different way?"* - *"Anything else?"* - **\[12\] Noting a discrepancy** (confrontation, challenging) - Observed discrepancies between two different statements they said **OR** stated feelings and the [way most others would feel] - NEVER criticize or attack - Should come across as caring and non-judgmental - *"On the one hand"* - *"I get the feeling"* - *"I see an inconsistency"* - \[Different than giving feedback -- telling clients what you have directly obersvered about their verbal and nonverbal behavior\] - **\[13\] Directing** (instructions) - Telling the client exactly what needs to be done -- w/in our scope of practice! - Normally education portion of the session - Clear and concise statements using evidence-based info - Determine if they understand - Sometimes helpful to have them repeat back - **\[14\] Advise** - Providing possible solutions for problems - To be effective should : - Be given in a nonjudgmental manner - Identify the problem - Explain the need to change - Advocate an explicit plan of action - End with an open-ended question to elicit a response - **Only given when:** - Have clear understanding of the problem - Previous attempts to deal with the problem have been investigated - You have a definite idea(s) for solution - **\[15\] Allowing silence** - Valuable tool - Gives space for internal reflection and self-analysis -- break to recover, reflect, get back on tract - After an emotional outburst, given the results of an evaluation, during instructions of a complex regimen - Break the silence by repeating the last sentence or phrase spoken by your client, or asking them what they thought during the silence - *"I can tell you have something on your mind. Tell me about that."* - **\[16\] Self-referent** (self-disclosing and self-involving) - Self-disclosing = involves providing information about oneself, generally about a coping experience - *"I have difficulty figuring out how to fit exercise into my day."* - Self-involving = actively incorporates a counselor's feeling and emotions into a session - *"I am delighted things are going so well for you."* - Remember you don't want to do this too much 24. **List the 4 steps in reflecting.** - **(1) Correctly identify the feelings being expressed.** - 5 major feelings: anger, fear, conflict, sadness, and happiness - Listen carefully, observe nonverbal behavior and voice quality - Intuition - **(2) Reflect the feeling you have identified to the client.** - Drop tone of your voice at the end of the statement; do not bring it up like you are asking a question - Stem tentative phrase: - *Perhaps you are feeling...* - *I imagine that you're feeling...* - *It appears that you are feeling...* - *It sounds like...* - *It seems that...* - **(3) Match the intensity of your response to the level of feeling expressed by the client.** - Use modifying words such as: - *a little, sort of, or somewhat* to soften the response - *really, very, or quite* to make the feeling response stronger - When in doubt use a milder term of the feeling \[See Table 3.7 Feeling Words\] - **(4) Respond to the feelings of your client, NOT to the feelings of others (spouse, family members).** - Use to encourage your client to continue talking and to help clarify their issues/problems 25. Understand the circumstances that brought a client to you might be important for you to understand. **[Chapter 4: Meeting Your Client -- The Counseling Interview]** 1. **Label the 4 phases of the MI algorithm and describe what happens in each phase. List major [goal] for all three phases in the algorithm. List major [tasks] for each phase.** - **[MI Algorithm]** = a step-by-step guide to direct the flow of a nutrition counseling session - Incorporates concepts from TTM, MI, solution-focused therapy, and self-efficacy **(1) Involving** **(2) Exploration -- Education** **(3) Resolving** **(4) Closing** An illustration represents the motivational nutrition counseling algorithm. The algorithm involves four phases: involving phase, exploration-education phase, resolving phase, and closing phase. The involving phase includes the following processes: establish comfort, review agenda, and invite input. The exploration-education phase includes the following processes: assess food behavior and activity patterns; explore problems, skills, and resources; provide nonjudgmental feedback; provide education and show results; elicit client response; assess readiness to change. The resolving phase shows the Tailor intervention approach leading to three levels. Level 1: not motivated, not ready. Goal: raise doubt. Keys: raise awareness, personalize benefits, promote change talk, respect decision, summarize, and offer professional advice. Level 2: unsure, low confidence. Goal: build confidence. Keys: explore ambivalence, explore barriers, imagine the future, explore successes, encourage support, summarize, and ask about the next step. Level 3: motivated, confident, ready. Goal: develop an action plan. Keys: praise positive behaviors, identify options, negotiate realistic short-term goal/s, and develop an action plan. The closing phase includes the following processes: support self-efficacy, summarize issues and strengths, and arrange follow-up. A double-arrow labeled establish and maintain an effective relationship: attending, reflection, legitimation, support, partnership, and respect is present next to the phases. - The main idea is that depending on what you assessed as the readiness scale for you client, that will tailor the resolving phase (the interventions) -- helps us focus on how are going to intervene w/ our client. +-----------------------+-----------------------+-----------------------+ | **MI Algorithm | **Objectives/Goals** | **Tasks** | | Phase** | | | +=======================+=======================+=======================+ | **(1) Involving** | \- Establish rapport, | \- Begin w/ greetings | | | trust, comfort. | and introductions. | | | | | | | \- Communicate an | \- Identify | | | ability to help. | **client's long-term | | | | behavior change | | | \- Interact in a | objectives**. | | | curious and | | | | non-judgmental | \- Explain rationale | | | manner. | for recommended diet. | | | | | | | | \- Explain counseling | | | | process. | | | | | | | | \- Set agenda. | | | | | | | | \- Summarize. | +-----------------------+-----------------------+-----------------------+ | **(2) Exploration -- | \- Provide | \- Offer educational | | Education** | information. | activities. | | | | | | | \- Show acceptance. | \- Assess food | | | | behavior, activity | | | \- Learn nature of | patterns, and past | | | problems and | behavior change | | | strengths. | attempts. | | | | | | | \- Promote | \- Explore problems, | | | self-exploration by | skills, and | | | the client. | resources. | | | | | | | \- Clarify problems | \- Give | | | and identify | non-judgmental | | | strengths. | feedback. | | | | | | | \- Help the client to | \- Elicit client | | | evaluate the | response. | | | situation. | | | | | \- **Assess readiness | | | | to change**. | +-----------------------+-----------------------+-----------------------+ | **(3) Resolving** | \- Help the client | \- Tailor | | | make decisions about | intervention to the | | | behavior change. | client's motivational | | | | level. | | | \- Indicate that the | | | | client is the best | | | | judge of what will | | | | work. | | +-----------------------+-----------------------+-----------------------+ | Resolving: **Level 1 | \- Raise doubt about | **Inform and | | -- Not Ready** | present dietary | facilitate | | | behavior. | contemplation of | | Ruler = 1-3 | | change.** | | | | | | (Precontemplation | | \- Raise awareness of | | Contemplation) | | the health | | | | problem/diet options. | | | | | | | | \- Personalize | | | | benefits. | | | | | | | | \- Ask open-ended Qs | | | | to explore importance | | | | of change & promote | | | | change talk. **Elicit | | | | self-motivational | | | | statements regarding | | | | importance.** Elicit | | | | identification of | | | | motivating factors. | | | | | | | | \- Summarize. | | | | | | | | \- Offer professional | | | | advice, if | | | | appropriate. | | | | | | | | \- Express support. | +-----------------------+-----------------------+-----------------------+ | Resolving: **Level 2 | \- Build confidence | **Explore and resolve | | -- Unsure** | and increase | ambivalence.** | | | motivation to change | | | Ruler = 4-7 | diet. | \- Raise awareness of | | | | the benefits of | | (Contemplation | | changing and diet | | Preparation) | | options. | | | | | | | | \- Ask open-ended Qs | | | | to explore confidence | | | | and promote change | | | | talk. Elicit | | | | self-motivational | | | | statements regarding | | | | confidence. Elicit | | | | identification of | | | | barriers. | | | | | | | | \- Explore | | | | ambivalence by | | | | examining pros and | | | | cons. Client | | | | identifies pros and | | | | cons of not changing | | | | and of changing. | | | | | | | | \- Imagine the | | | | future. | | | | | | | | \- Explore past | | | | successes. | | | | | | | | \- Encourage support | | | | networks. | | | | | | | | \- Summarize | | | | ambivalence. | | | | | | | | \- Ask about next | | | | step. | +-----------------------+-----------------------+-----------------------+ | Resolving: **Level 3 | \- Negotiate a | **Facilitate | | -- Ready** | specific plan of | decision-making.** | | | action. | | | Rule = 8-10 | | \- Praise positive | | | | behaviors. | | (Preparation Action) | | | | | | \- Explore change | | | | options. Elicit | | | | client's ideas for | | | | change. Look to the | | | | past. Review options | | | | that have worked for | | | | others. | | | | | | | | \- Client selects and | | | | appropriate goal. | | | | | | | | \- Develop action | | | | plan. | +-----------------------+-----------------------+-----------------------+ | **(4) Closing** | \- Provide support. | \- Support | | | | self-efficacy. | | | \- Provide closure. | | | | | \- Review issues and | | | | strengths. | | | | | | | | \- Restate goal(s). | | | | | | | | \- Express | | | | appreciation. | | | | | | | | \- Arrange follow-up. | +-----------------------+-----------------------+-----------------------+ 2. **List the 4 methods to determine which stage of change your client might be in.** - The MI counseling algorithm requires you to make an assessment of readiness to change for every, single client - \(1) **Stages of change algorithm** - Ex: Figure 4.3 -- Algorithm of questions in a client assessment questionnaire - Usually given to a patient PRIOR to counseling/assessment session - \(2) **Readiness-to-change open ended questions** - Asked during the initial assessment session w/ client - *"How do you feel about making a change now?"* - *"People differ in their desire to make changes. How do you feel?"* - \(3) **Readiness-to-change scale questions** - "On a scale from 1 to 10, with 1 bring 'not at all' and 10 being 'totally ready', what number would you pick that would represent how ready you are to make this change?" - Follow up Q: "*Tell me why you chose 8 instead of a 10? Why did you pick that number?"* - Can also be used to asses: - Dietary adherence to the diet prescription previously provided (during follow-up sessions) - "How well did you adhere to not consuming sugar-sweetened beverages on a scale of 1 being 'never follow the guidelines' and 10 being 'always follow the guidelines'?" - Importance and confidence to make changes - "How important is this change to you on a scale of 1-10 w/ 1 being 'not important' and 10 being 'very important'?" - If change is not important at all to client adjust intervention - "How confident are you that you can make this change?" - \(4) **Readiness-to-change graphic** - Graduated picture of a thermometer, rule or chart (ex: figure 4.4) - Ex: form 4.1, appendix D -- Lifestyle management form 3. **List acute care considerations an RD might need to consider in the inpatient setting.** - New hospital admission - Pt may not know why you are there - Nutrition risk screening - MD consult - Introduce yourself: verify you have the correct patient - Explain why you are there - Ask if it is a good time to meet with them - Understand stress of being hospitalized -- sicker, shorter stays - You want to optimize your time with them. - There is not as much counseling in hospital settings because you have such little time w/ them. - It is more education-heavy, but you should still use same MI skills to reveal intrinsic motivation to make changes. - Consider scheduling an outpatient visit for follow-up; have MD put in consult - Make sure they have a support system in place when they leave the hospital. Ex: DM Session; PT referral - If ambulatory, maybe take them to your office. - The more comfortable you can make your patients, the better. +-------------+-------------+-------------+-------------+-------------+ | | **Developme | **Nutrition | **Determina | **Intervent | | | ntal | al | nts | ion | | | Factors** | Risks | of Food | strategies* | | | | (according | Behavior** | * | | | | to HEI)** | | | +=============+=============+=============+=============+=============+ | | Qualitative | \- Adequate | Family, | **Goal: | | | ly | in milk and | culture, | healthy | | | different | fruit | media | growth and | | | from an | | | development | | | adult | \- Commonly | \- Foods | ** | | | | deficient | provided by | | | | \- | in iron, | family | **Focus: | | | Creative, | zinc, | | nutrient | | | fanciful, | calcium | \- Foods | density, | | | cognitive | | specific to | appropriate | | | world | \- Soda and | culture | portions** | | | | juice | | | | | \- | replacing | \- | \- **Limit | | | Beginning | milk | Advertiseme | digital | | | to think | contributes | nts | media | | | symbolicall | to calcium | (Preschoole | time** to 1 | | | y | deficiency | rs | hr/day | | | for objects | | cannot read | | | | | | but can | \- Involve | | | \- | | identify | family/care | | | Understand | | the | givers, | | | cause and | | McDonalds' | consistent | | | effect | | logo.) | messaging | | | (cannot | | | | | | understand | | Picky | \- Provide | | | food | | eaters, | action-orie | | | advertising | | food jags | nted | | | vs. regular | | (want | behavior | | | TV program) | | specific | change | | | | | food only), | activities | | | \- Emerging | | reluctance | like | | | independenc | | to try new | hands-on | | | e | | foods | activities, | | | -- | | | creative | | | exploring | | \- Eating | and fun, | | | | | patterns | food | | | \- Touch, | | change. | tastings, | | | feel, | | Child may | plan meals; | | | manipulate, | | eat | shop for | | | question, | | anything | and prepare | | | compare, | | offered, | foods | | | identify | | then begin | together | | | objects | | refusing | | | | | | foods | \- Creative | | | \- | | | food | | | Accumulate | | \- Test | records: | | | and process | | independenc | draw | | | -- | | e | pictures, | | | observing, | | | put line | | | modeling, | | \- | through | | | role | | Decrease/in | pictures | | | playing, | | crease | after | | | behaviors | | in growth | eating; | | | of parents, | | | parental | | | teachers, | | \- Taste | food | | | kids | | preferences | diaries | | | | | for | | | | \- Cannot | | sweet/famil | Parental | | | make | | iar | advice: | | | informed | | foods | | | | decisions | | | \- Choose | | | but can | | | between 2 | | | state | | | good | | | likes/disli | | | choices | | | kes | | | | | | | | | \- **"no | | | | | | thank you | | | | | | bite"** | | | | | | | | | | | | \- | | | | | | Introduce | | | | | | new foods | | | | | | at the | | | | | | beginning | | | | | | of a meal | | | | | | | | | | | | \- Make | | | | | | meals | | | | | | attractive | | | | | | and | | | | | | colorful | | | | | | | | | | | | \- Minimize | | | | | | food as | | | | | | reward | | | | | | | | | | | | \- Maintain | | | | | | positive | | | | | | atmosphere | +-------------+-------------+-------------+-------------+-------------+ | | Time of | \- Intake | Family | Behavioral | | | major | worse than | | interventio | | | cognitive, | 2-5 y/o. | \- Parents' | ns: | | | social, & | | eating | | | | physical | Needs: | habits | \- | | | development | | | Self-monito | | | | \- | \- Food | ring | | | Want to | Increase: | available | of diet and | | | understand | whole | in home | physical | | | people and | fruit, | | activity | | | the world | whole | School | | | | around them | grains, | | \- Cue | | | | dark green | \- Food | elimination | | | \- | and orange | standards | : | | | Differentia | vegetables, | (USDA | visual | | | te | legumes | school | | | | between | | foods) | \- Stimulus | | | "kid world" | \- | | control | | | and "adult | Decrease: | \- | | | | world" | saturated | Nutrition | \- | | | | fat, | education | **Goal-sett | | | \- Develop | sodium, | | ing** | | | theories on | extra | Screen time | | | | how the | calories | (\~4.5 | \- | | | world works | from solid | hrs/d) from | Action-plan | | | | fats and | TV, | ning | | | \- Greater | added | computer/in | | | | self-unders | sugars | ternet, | \- Modeling | | | tanding | | gaming, | | | | | \- | phones | \- Limit | | | \- Capable | **Overweigh | | setting | | | of | t | \- Slows | | | | theorizing | and obesity | metabolism | \- | | | | major | | **Contingen | | | \- Able to | issues** | \- | cy | | | understand | | Increased | management | | | function of | | snacking/po | & positive | | | food and | | or | reinforceme | | | its | | food | nt:** | | | influence | | choices | involve | | | on health | | | giving | | | and growth | | \- | tangible | | | | | Susceptible | rewards to | | | \- Develop | | to food ads | reinforce | | | self-esteem | | (see | positive | | | and | | \~11.3/d) | behavior | | | self-worth | | | | | | | | | \- | | | \- Desire | | | Differentia | | | for | | | l | | | autonomy | | | attention: | | | (self-regul | | | catch them | | | ation) | | | being good | | | | | | | | | Mastery of | | | Multiple | | | physical | | | component, | | | skills | | | family-base | | | | | | d | | | \- Playing | | | interventio | | | sports | | | n | | | | | | | | | \- Enjoy | | | \- | | | physical | | | Parenting | | | activity | | | can | | | | | | influence | | | \- Body | | | attitudes, | | | growing | | | preferences | | | muscles and | | | and values | | | developing | | | of food | | | | | | behavior | | | Developing | | | | | | social | | | **Limit | | | skills | | | media | | | | | | screen time | | | \- Friends | | | to | | | are | | | \