Last issue we spent time exploring how questions can be used to seek exceptions to a problem behaviour. Uncovering these exception experiences can reveal overlooked or dismissed resources. Reconnecting our clients to these resources is a powerful intervention that can reinforce our client's competence and autonomy in the change process. If you'd like to have a quick revision you can access Issue 25 below
Sue Zbornik APD demonstrated a beautiful application of the exception idea at her Appetite Workshops in February. I invited Sue to contribute to this issue and talk a little about this special form of conversation she has with her clients.
Read on to engage with this wonderfully creative application of the 'Exception Question'
So let's see, in Issue 24 we spent some time thinking about directive questions that pull out our client's preferred future by eliciting resources, strengths and visions of change. Broadly called 'Solution Focused' questions these types of questions are a powerful tool in the kit bag of behaviour change therapists.
Travelling along a similar vein in this issue, I am inviting exploration of questions that look for exceptions to the problem. These types of questions may offer a much more subtle and client focused alternative to imposing a new thought about change. 'Exception Questions' may do this by inviting the client to sift through their own experiences with a lens that captures times when the problem has been less of an influence.
Read on to explore more about what this angle of enquiry may have to offer your clients and what it may sound like in session...
I'd like to start with a story from a book I am currently enjoying. The story is called 'The Dog I Feed Most'. It goes like this:
A Native American elder described his inner struggle in this manner: 'Inside of me there are two dogs. One is mean and evil; the other dog is good. The mean dog fights the good dog all the time'. When his grandson asked him which dog won, the elder replied: 'The one I feed most'
From: 101 Solution Focused Questions for Anxiety. 2015 Fredrike Bannink
In this issue we are exploring what sort of questions 'feed the good dog' in our client? ......questions that elicit information that is of most benefit to our client's forward movement and successful behaviour change process.
Following in the footsteps of the first anniversary edition this issue collates a synopsis of the year's issues with handy links to each issue's full editorial. Due to the popularity of the 2014 CPD Quiz a 2015 CPD Quiz has been included in the Purple Pavestone box at the end of the issue summaries. You can buy the quiz to test your knowledge and convert your dedicated reading of Practice Pavestones into assessed CPD hours for your APD renewal.....just around the corner. Please support Pavestones by sending on to APD colleagues who may be looking for great value assessed self-study in this vital area of practice.
As mentioned in the wrap up of last issue, this editorial will be exploring in more detail the formulation of open questions and we'll get some practice in converting closed to open questions using handy word stems.
'Word Stems' for Open Questions
Typical choices for getting your questions off to an open start include:
This is in contrast to these typical closed question openers:
Read the rest of the issue to consider some examples of using these word stems in effective open question formulation
For a stunning 'Captain Obvious' I'll start with this definition of a question from The Oxford Dictionary:
a sentence worded or expressed so as to elicit information.
Pretty straight forward. But do we stop to think what kind of information is most beneficial to our client to elicit?
Most health professionals receive lengthy training in assessment and are well rehearsed in asking questions. But what about asking questions with purpose beyond our intake form? If a primary focus of client centered work is to explore our client's ideas and experience, how can we be aware of the type of questions that can open up exploration and those that can close it down?
To answer this, it can be helpful to consider questions in two basic classes: Closed and Open. Let's take a quick tour of the difference and pros and cons of each. Download this issue to find out more
A central tenet of client centered work is that the client’s understanding of themselves and their lives is privileged over what the counselling professional may think or believe they ‘know’ about the client. The client is considered the expert in their lives.
This core idea can guide all aspects of our communications with our client. This includes the skill of affirming. When we focus on our client's ideas and knowledge of their strengths and positive qualities we are potentially opening up a powerful new aspect to this very helpful micro-skill. We are inviting co-creation and autonomy in affirming.
You may be able to hear the invitation for autonomy and co-creation in affirming in this quote from Motivational Interviewing 3rd ed :
‘The spirit of MI starts from a [….] strengths-focused premise, that people already have within them much of what is needed, and your task is to evoke it, to call it forth. The implicit message is ‘You have what you need, and together we will find it’ p21
Miller and Rollnick
So, in this issue we are exploring merging these two principal MI ideas:
Calling forth the client's knowledge and emphasising their autonomy (this reduces resistance and enhances empowerment in the change process)
Affirming our client's strengths (this increases hope and confidence to change)
Read on to discover more about this powerful skill mash up!
For those of you who are seasoned practitioners, you will be familiar with the very bumpy road that is characteristic of our clients' behaviour change process. If you are new to facilitating change in others I am sure that a minute of self reflection will confirm that even (or particularly!) for ourselves, 'being' different and 'doing' different is hard work requiring energy, focus and commitment.
It is not uncommon for our clients to share 'problem saturated stories' of repeated experiences of failure, lack of hope or even reluctance to be visiting our office to meet with us. It can be a genuine challenge to our skill of affirming to seek out our clients' strengths to reflect back to them when there's seemingly nothing 'going right'. The paradox is of course, that this can be a powerful time to do it. Demonstrating our willingness to notice capacity and capability in our client when they cannot see it for themselves can be a strong alliance builder.
So where to start?
I recently had a series of very humbling experiences.....listening to recordings of myself at work with clients. I was required to record several client sessions to analyse my skills for a training application that was due this month. In this process of listening and self analysis (and with mentoring from my Skills Coaches), I discovered that my affirming needed some work.
One thing I was surprised to learn is that when I engage in affirming I can sometimes inadvertently ask a question by ending the affirmation with an upward voice inflection. Easily done (especially if you are an Aussie). Not necessarily harmful but also not particularly helpful.
These recent experiences of mine got me thinking about this next issue. Now that I have lead the way, I thought we might explore ways that we accidentally stuff our affirmations up.
Quick Menu of Affirmation 'Stuff Ups'
Here's a wee check list of three easy ways we might go off track when trying to practise the skill of affirming:
Download this issue to read some examples of what these 'stuff ups' may sound like and some strategies for correcting them...
In Issue 16: Working With Our Clients' Strengths, I finished up with the following suggestion for reflection:
If you are new to affirming you may like to practice by:
Following on from a group discussion in the last training workshop, I thought it may be valuable to list some examples of strengths and attributes we may encounter in our clients.
Below is a list you may like to consider and reflect on. It is largely inspired by 'The Library of Strengths' in Stephanie Dowrick's book Choosing Happiness (Penguin 2007). Download to contemplate more.....
For most people struggling with change, being really heard is a very encouraging and positive experience. Past issues of Practice Pavestones have featured lots of discussion about the power of reflective listening in assisting our clients this way. Affirming takes the skill of reflective listening one step further to amplify the positive effects of being heard and understood.
In the course of a session, clients can say an awful lot to us. What we select from our clients' statements to reflect back to them can have a real influence on our client and the direction of the conversation in session. As we become more skilled at active listening we can become more deliberate in what we highlight to our client in our reflective responding.
Affirming is the intentional act of reflecting back to our client something about:
Here's a great definition from David Rosengren:
'Affirmations are statements of appreciation for the client and his or her strengths. ....The statements are strategically designed to anchor clients to their strengths and resources as they address their problem behaviour' p 62
When we affirm, we sift through our clients dialogue and actions and creatively highlight aspects of forward movement. To read more on what this may sound like and the practitioner attributes involved go for the download!
In this issue we are going to be exploring a little about clients who talk more than others and the challenges this may place on our practice of reflective listening.
We are all familiar with the scenario. We invite our client to speak and within a short period of time we are getting that uneasy feeling.........'whoa...where is this going?' . We may start to panic, there is time to keep, the next client will be here in 15 minutes, we need to 'get to the point' but we know the value of reflecting and attending. It can all get us a bit overwhelmed.....
It can be very hard to know what to attend to and what to reflect when the client has done the metaphoric, story-telling equivalent of turning their handbag upside down and letting gravity work its magic. Or man-bag. It would be dangerous to assume that it is only our female clients who can be the talkative ones.
A Strategy to Consider
There are many reasons why some clients talk a lot. One is anxiety. Meeting with a Dietitian or talking about stressful behaviours can be extremely anxiety provoking. Long and complex stories are often a symptom of a hyper-aroused state and can be (unconsciously) functional in providing a great distraction.
Anxiety in our client is important to acknowledge as it points to some ways we can be helpful in this situation. Here's a handy acronym to get a handle on things:
Read on to find out more
Responding reflectively to our clients can be a challenging skill to develop when we are trained in advisory and solution focused models. In the counselling skills training group this week we brainstormed together all of the possible road blocks to reflecting with our clients.
Here is a summary of what was collated:
To bring these road blocks to life, let's consider how these challenges may appear in response to the following client statement:
'My last diet resulted in me gaining 5 kg more than I started with. It was a disaster.'
Read on to learn more.........
So far we have explored Active Listening through the skills of attending (Issues 7 - 11). Whilst attending is always our first step in engaging in Active Listening, the process would be rather futile if sitting in silence was all we did, no matter how perceptive we were.
Active Listening is as much about how we respond to our clients' communications as it is about how we attend to our clients' communications... this may be in part why this form of listening is called Active not Passive Listening.
Helpful Responses in the Active Listening Process
We can engage in both helpful and unhelpful responses when we listen to our clients. Our responses to our clients' disclosures have the capacity to keep the talk about the client and their experiences or start to make it about us (what we know, what we what them to do and all that jazz). Our responses have the capacity to close the exploratory conversation down or open the exploring up. Our responses can enhance safety and acceptance or invite a subtle tone of expectation or even judgement.
No prizes for guessing which of those options is more helpful!
For this issue I'd like to briefly explore helpful responses in three rough categories. Read on to understand more and what these responding categories may sound like in session with a client..
On December 8, 2013 Issue 1 of Practice Pavestones was sent out to 54 brave subscribers (they signed up without knowing what they were going to get!). Since then we have had 12 monthly editions, a fabulous two day training intensive and the subscription base is now sitting at over 820! Your enthusiastic feedback has been a huge motivator for content and ongoing improvement and development. THANK YOU!
This issue is offering you the opportunity to consolidate and reflect on your learning so far. You can revisit a favourite issue or, for new subscribers, get a chance to catch up on previous issues you may have missed.
IN THIS SPECIAL BUMPER EDITION you'll find:
As health professionals, we are trained to use our minds in the listening process to listen evaluatively. Listening evaluatively enables us to perform two very important functions within the medical model of patient care:
1. Assess our client's nutritional health
2. Formulate an appropriate intervention, education or prescription.
Our skill as evaluative listeners is a hand in glove match for performing the role of helper in the medical model. However, when we start to segue into the client centered model, evaluative listening can often prove to be something of a hindrance. Let's explore why.
Through our training, we are often oriented towards spending valuable listening energy formulating responses and advice whilst our client is talking. Our busy and eager 'helping mind' can really get in the way of effectively attending to our clients' messages. This can cost us valuable engagement and can also set us up to work much harder than our client.
Let's consider too that when our clients are struggling it can be so tempting to step out of listening and engage in some quick 'installation therapy' i.e. telling the client what we know to make them 'better'. And we often know a lot of really useful stuff! But as many of us have learned the hard way, installation therapy rarely works..........
.......our client may simply not be ready to hear what we know
......what we know may be irrelevant (ouch)
...........or our client may have a much better idea of what they need to do!
So when we need to be listening, what are we to do with our expert knowledge and urge to help? Neither are wrong, it's just how we harness them that keeps them useful. As a place to start, it can be helpful to remember the power of keeping our client front and center and our ideas second place. Read on for some tips on this challenging process...
.....Hmmmm a challenging issue to write this one.
The first challenge: how to define the function of 'heart' in the listening process.
The second challenge: keeping this exploration relevant to our work as Dietitians or any other health professional immersed in the objective medical model.
Defining 'Heart' in the Process of Active Listening
What do we mean when we refer to 'heart' in the listening process? This is open to many interpretations - all with merit.
In this sense we may consider that listening with heart could be defined as Empathic Listening - sensing into the emotional content of our client's communication.
I'd like to also suggest that an extension to the definition of 'heart' in the listening process could include 'body'. In this way we might use the word 'heart' as a proxy for the data within our Body's Felt Sensing that we experience when we attend to our clients.
For some, the concept of Right Brain comes closer to defining 'heart' in tuning into our clients. In this sense Right Brain may be appreciated as offering the more fluid, creative, intuitive aspects of our connecting with our clients and the meaning making process. In Issue 9 I touched on this a little when considering our clients' verbal messages and pondered the idea of 'whole-brained' attention. If this fascinating aspect of communication interests you...and to read more about what it may sound like in your sessions with clients ...read on.
When we think of 'tuning into our clients', our most obvious attention point is our clients' verbal messages i.e. - what they are actually saying to us in words. Particularly for our objective data collection as health professionals, understanding our clients' verbal messages is essential.
When we are listening to our clients talk, it can be useful to consider these three areas of experience that our clients may be verbally describing:
What they are thinking
How they are feeling
What they are doing
As Dietitians, our training tends to focus on recording and analysing very specific aspects of data within the frame of what the client is doing. For example - when do you eat?, what do you eat?, what is your body doing? (symptoms, bloods etc) what medication do you take?...doing doing doing doing.........
This data is often very important, particularly when we are new to the work. Typically we need this data to assess aspects of nutritional quality, nutrients, metabolic response and how the human body seeking our assistance is operating.
So what's the problem with honing in like this on the 'doing data' ? Well, when it comes to working with eating behaviors it often misses the point..read on to find out more
When we think about the data we collect when we listen, usually the first thing that comes to mind is the words that we hear. While this is of course essential, we are all familiar with the expression 'Actions speak louder than words'. In the process of fully understanding the communications of another human being, it is well established that we privilege non-verbal messages over verbal. So, for this first issue on attending, it made sense to start with a discussion about attending to our clients' non-verbal messages.
What are Non-Verbal Messages?
Often referred to broadly as 'Body Language', non-verbal messages may be considered in discernible parts. Egan in 'The Skilled Helper' defines these parts as:
Bodily Behaviour - posture, movement and gestures
Facial Expressions - self explanatory!
Vocal Behaviour - tone of voice, speed of speaking, pausing, volume of speech
Physiological Responses - often autonomic such as flushing, sweating or quickening of breath
Physical Characteristics - including appearance and body size (need to be used cautiously!)
To find out more about the usefulness of non-verbal messages in eating behaviour counselling and what working with these messages may sound like - read on!
Listening in a therapeutic or helping relationship is a much more active process than the behaviours we might get away with in our day to day interactions. No surprise then that this core skill is referred to as Active Listening. I often think of Active Listening as Listening on Purpose
Active Listening is central to the effective functioning of a helping relationship. Being truly listened to is key to the experience of being valued, understood and 'allowed'.
Even when our role necessitates a strong education focus, Active Listening performs a vital function. As they say: 'If you can identify, you can rectify!'. Listening properly to our clients helps us to provide the 'right' education for their needs.
Judy Gamble writes a great definition of Active Listening in her book 'Counselling Skills for Dietitians': 'Active Listening .......is a dynamic process which involves the skill of attending, i.e. giving someone our whole-hearted attention.' p60
Let's pick up with this notion of 'Attending'....read on!
In this Issue of Practice Pavestones we will be exploring the last core attribute in our client centered practice: Unconditional Positive Regard. So how does Unconditional Positive Regard contribute to relief, acceptance, motivation and other experiences that our clients really value?
What is Unconditional Positive Regard (UPR)?
UPR is a disposition or attitude towards our client whereby: 'the client is viewed with dignity and seen as a worthwhile human being' Phillip Burnard
This attitude accepts that our clients have a right to their subjective reality and is offered without conditions.
When a client experiences UPR they often report feeling:
genuinely cared for by their health professional
praised spontaneously and authentically
supported without strings attached
To find out more about how UPR helps and what is might sound like in session read on. I hope this exploration gets you thinking......
In this Issue of Practice Pavestones I am going to be discussing the core client centered attribute: genuineness and warmth. A subtle and sophisticated attribute, I'd like to start by considering this dilemma, I am sure familiar to many of you:
Your client comes in to session - all smiles and energetic. You are welcoming and reflect her positive state in your body and voice. You begin to explore together the reason for her coming to see you and she shares her enthusiasm for getting your help to 'lose weight'.
You start by inviting some story telling. You might say... 'Have you tried to lose weight before? Can you tell me a little about those experiences?'
What follows is a long tale of repeated failures, weight cycling, suffering and self blame......and yet the client seems completely unmoved - ready to go again, smiling ....
Something in you says 'This doesn't match!' You are reflecting her positivity but hearing her desperation. You might be aware of a weird kind of strain or a sense of confusion in you. You know in yourself the client is incongruent. What she is saying and what she is feeling don't line up.
At this point, as the Dietitian, we have a choice:
We can ignore what we feel and continue to fall into the client's slip stream of blind faith. Result: two people pretending in the room!
We can recognise the opportunity to be genuine. We can lean into our sense that something isn't right and be transparent with our client about what we are sensing.
I hope you enjoy pondering the benefits of being warm and real with our clients in this issue of Practice Pavestones...
To underscore the importance of the therapeutic relationship in quality Dietetic work I would like to share with you a message I received from Joanne Ikeda:
'I very much appreciate Issue 3 of your newsletter. For over 20 years, I taught nutrition education and counseling to dietetics majors at the University of California, Berkeley. The very first thing I taught my students was the importance of establishing an effective helping relationship with clients. I am glad to see this reinforced in your newsletter.'
Joanne Ikeda, MA, RD, Nutritionist Emeritus, University of California, Berkeley
In this Issue of Practice Pavestones I am going to be focusing in on one of the core attributes underpinning the formation of this effective helping relationship - Empathy. How does empathy play a role in practicing effective Dietetic counselling? Let's to start this exploration by considering a recent real life scenario:
Dietitian: 'Mary, I'm wondering as we near the end of your session today how it was for you to share with me the story of your ups and downs with eating so far?'
Mary: 'It was good -...'
Dietitian: ..(gently) ......'Good?'
Mary: 'Yeah you really understood where I was coming from. I think you can help me'
What Mary is really saying here is that the experience of being understood left her feeling that she could be helped.
This is the power of empathy in a nutshell. It enables a connection which sits in direct contrast to the sense of isolation that comes with a difficult problem. It is this isolation that often drives despair, shame and entrenchment of behaviours. With empathy, it is in our power to give our clients a new experience of relating to their problems. Can you hear the subtle motivational edge in Mary's observation above? If this idea interests you, you are welcome to download the full issue....
There are so many counselling modalities offered to Allied Health Practitioners to assist in helping their clients: ACT, CBT-E, MI...to name a few. Recently I was asked by a colleague which counselling modality was the 'best one to start with' for Dietitians. My short answer to this question is Motivational Interviewing (MI)- a great starting place for health professionals working in behaviour change. For a more comprehensive response there are some really important issues to consider beyond choosing a 'best fit' modality. Knowing where to start can be confusing and a tad overwhelming!
With the risk of actually adding to the confusion I am going to be quite challenging and say – take great care with how you begin with any of the modalities above! Let me share more…….
Thanks for all of your great feedback from Issue 1 of Practice Pavestones. Following on from this issue I had a number of readers ask a very similar question regarding how to remain client centered whilst also providing advice. This is such a great question I thought I would feature this in Issue 2.
To start, let's imagine this (real life) scenario.
A client Mary, is nearing the end of her session with her Dietitian. The Dietitian enquires as they are winding up:
‘Mary, I’m wondering what stood out for you today in our discussion? What felt helpful to you?’
Mary reflects, takes a minute and responds
'You listened to me and you didn't’ tell me what to do, it is such a relief!’
The client goes on to describe a couple of ideas she has taken from session she would like to work on or pay attention to.
How was this achieved without leaving the client feeling advised? Given the Dietitian is traditionally there to give advice and probably did during various stages of the session - how are we to understand this comment? What is going on!?
Giving advice can be a vital part of being helpful but depending on HOW we do it we can run the risk of disempowering our client or rupturing our working alliance. If you are called upon to advise in your work with clients ………you are encouraged to read on!