Final Exam

Question 1

Differentiate intellectual quotient (IQ) from emotional intelligence (EI)

Answer 1

IQ
o High erudition
o All learning gained from books
o Can quote any law or formula in any situation
o The “walking, talking encyclopedia” type

EI
o	Instinctive and intuitive
o	Less nerdish, more street smart
o	Learning from interaction
o	Ability to manage any situation

Question 2

Define professional helping

Answer 2

• Involves responding to feelings, thoughts, action and social system of clients
• Is characterized by confidentiality and privacy
• Focuses on the needs and disclosure of the client rather than the counselor

Question 3

Describe the steps in the counseling process

Answer 3

1. Relationship building
2. Problem Assessment
3. Goal setting (when at appropriate stage of change)
4. Counselling intervention
5. Evaluation, termination or referral

Question 4

Name and describe the 2 phases of the helping relationship

Answer 4

Phase 1: Building a relationship
• Requires good rapport with client
• Ability to show empathy
• Formation of a trusting relationship so the client can disclose information to you

Phase 2: Facilitating positive actions
• Help client identify specific behaviour to alter
• Design realistic behaviour change strategies to facilitate positive action

Question 5

Describe the listening process

Answer 5

Hearing and remembering verbal and non-verbal information –> Selecting and sorting information, ideas and feelings –> Understanding meaning and emotions –> responding

Question 6

What 3 verbal responses can communicate to clients that you are listening to them?

Answer 6

 Paraphrase
 Reflection
 Summarization

Question 7

Describe active listening

Answer 7

• Is a cluster of skills used to increase accuracy of meaning
• Builds rapport
• Does not threaten people with an over attempt to change them
• Includes skills in: attending, being silent, summarizing, paraphrasing, questioning and empathizing
• Involves earing what is said and what is left unsaid
• Involves paying careful attention to cues:
  o Word choice
  o Tone of voice
  o Posture
  o Verbal hesitations

Question 8

Define empathy. What does it imply?

Answer 8

The ability to understand the client’s experience and feel with or emotionally resonate to the clients experience as if it were your own but without losing the “as if”
Empathy involves being sensitive and needs to feel genuine.

It is NOT:

• merely supporting or agreeing with the client
• pretending to understand
• taking on your client’s problems
• a one-time behaviour (crucial that it is present throughout the counselling process)

Question 9

How does empathy contribute to the counseling relationship?

Answer 9

• Encourages expression of emotions
• Normalizes and validates feelings
• Reduces isolation of client
• Increases awareness of emotions, including ambivalent feelings
• Stimulates further exploration of client’s subjective experiences
• Helps client recognize the impact of emotions on themselves and others
• Assists clients to understand how emotions influence decision making of how they impede action
• Provides a starting point for managing and expressing emotions in constructive ways

Question 10

Name 7 ways in which empathy can be demonstrated.

Answer 10

Eye contact
Muscle of facial expression
Posture
Affect
Tone of voice
Hearing the whole patient
Your response

Question 11

Differentiate empathy from sympathy.

Answer 11

Empathy: Just listen
Sympathy: Give unasked advice

Empathy is the ability to experience the feelings of another person. It goes beyond sympathy, which is caring and understanding for the suffering of others
Empathy is not interpreting: the counselor should respond to the client’s feelings and should not distort the content and what the client is telling the counselor

Question 12

What is empathetic listening?

Answer 12

Centers on the kind of attending, observing, and listening needed to develop an understanding of clients and their worlds.

Question 13

Name the 6 relationship building responses

Answer 13

• Attending
• Reflection
• Affirmation
• Respect
• Partnership
• Personal support

Question 14

What is Interviewing?

Answer 14

A special type of interpersonal communication which is purposeful and serious, usually involving questions and answers, with the goal of sharing information or facilitating therapeutic outcomes.

Part of an assessment process that helps the counselor be a more effective helper as it permits to confirm that you are in the right direction and addressing the right issues.

• Important to acquire and organize relevant information through timely listening and responding
• Indispensable for effective counseling – counseling and interviewing are always together. To be a good counsellor, you need to be a good interviewer

Question 15

Explain the 4 parts of an interview.

Answer 15

1. Preplanning
   - Interview guide, reading chart
   - Physical environment (Distance/proximity (personal space), Privacy)
   - Patient context
   - Psychological privacy
2. Opening (involving)
   - Greeting and introductions (safe talk) “Is it your first time seeing a P.Dt? What brings you here today?”
   - Statement of purpose
   - Explain counseling process
   - Set agenda (summarize what you will go through during the time you have with them, what the time limits are)
   - Development of rapport
3. Body of an Interview
   - Sequence of topics
   (Assessment –> Explore problems, skills and resources –> Assess readiness to change –> Non-judgemental response
   - Maintenance of rapport
4. Closing/ending of interview

Question 16

What is the role of questioning in the interviewing process?

Answer 16

• Questions assume and encourage an active role for the client in the process of changing the behaviour
• Questions are important interviewing tool for gathering information, providing focus to the interview, promoting client’s insight.
• Good questioning might lead the client through problem solving and can help the client to examine areas they might have overlooked.
• Involve using words such as which, when, why, who, where, how, what?

Question 17

Describe open questions, and their pros and cons.

Answer 17

• Begin an interview
• Encourages client to express more information
• Permit disclosure, depth
• Require more time and interpretation by the counselor
• Request a story from the client not just an answer
• Begins with: “what, how, who, where, when, why”
• Increase client’s sense of control: gives client control
• Require more effort in relating response to the information that you need
• Helps build rapport
• Encourages self-exploration, elaboration
• Can be a barrier to communication if not asked with a useful purpose of checking understanding or assessing knowledge

Question 18

Describe closed questions, and their pros and cons.

Answer 18

• Major tool to obtain information during the assessment phase
• Limit client responses (yes or no, a number, short answer)
• Begins with: “have you, did you, do you”
• Give quick answers/valuable information
• Lessen client’s sense of control: keeps client more passive
• To confirm or disconfirm a hypothesis
• Useful when the helper knows what he/she is looking for
• Narrowing the area of discussion by asking client for a specific response
• To gather specific information
• Could be used to interrupt an overly talkative client who “rambles”
• May discourage discussion if used excessively
• Useful and more frequently used for clients with limited mental ability and children
• Can effectively bring closure/ending to an interview
• Can slow the pace of a very “chatty” client
• Avoid using too many when the client tends to be very succinct

Question 19

What is the proper ratio of open-ended to closed-ended questions?

Answer 19

around 50:50 to 70:30

Question 20

How do we close/end an interview?

Answer 20

• Review what has occurred during session, a concluding kind of review or ask the client to summarize
• Avoid asking open-ended question not to re-open issues
• Express appreciation
• Restate goals
• Explain/arrange future contacts
• Nonverbal signals
“time is coming to an end”
“We will need to stop in a few minutes”
“It looks as if our time is up for today”
The closing is the responsibility of the counselor!

Question 21

What are the 4 models and theories of behaviour change?

Answer 21

1. Health belief model
2. Social cognitive theory
3. Reasoned action, planned behaviour theory
4. Stages of change model

Question 22

What are common features of the 4 models and theories of behaviour change?

Answer 22

Protection motivation
o “I am motivated to become physically active so I can protect myself from a heart attack”

Self-Efficacy
o The confidence to perform a given set of behaviours under specific circumstances

Reasoned action
o “I believe that as I follow a lower-fat diet, I’ll lose weight, look better, and reduce my chances of a heart attack”

Decisional balance
o Weighing the pros and cons of behaviour change

Question 23

Define self-efficacy

Answer 23

The confidence to perform a specific behavior (Albert Bandura)

People’s beliefs about their capabilities, abilities to accomplish something, to produce designated levels of performance that influence events that affect their lives.

Self-efficacy beliefs determine how people feel, think, motivate themselves, and behave.

Very important in attempting to perform a given behavior under specific circumstances

Question 24

What is self-efficacy mainly built on?

Answer 24

life experiences

Question 25

What are the 4 main factors influencing self-efficacy?

Answer 25

1. Performance accomplishment (for similar tasks) 2. Vicarious experiences (Someone similar to themselves) 3. Verbal persuasion (depends on the credibility of the person encouraging) 4. Physiological states: Emotional arousal a learner experiences, and how they interpret it (butterflies in stomach = stress? anxiety? or rather excitement?)

Question 26

How is self-efficacy measured?

Answer 26

S-E is rated on the General Self-Efficacy Scale (GSE) Score from 10 to 40 Higher score = higher self-efficacy

Question 27

What can a counselor do to promote self-efficacy in a client?

Answer 27

- Help clients identify their past successes - Encourage clients to make an inventory of their strengths and resources - Look for opportunities to affirm their client’s efforts, strengths and successes

Question 28

Explain the health belief model. Why was it first developed?

Answer 28

One of the first models developed exclusively for health-related behaviours Currently among the most popular models --> Developed in 1950s to understand why many individuals failed to participate in programs to prevent/detect disease. • A goal setting theory based on level of aspiration, in which the individual sets the target of future performance based on past performance. • Framework for understanding individual’s psychological readiness or intention to take a given health action. • States that people’s beliefs influence their health-related actions or behaviors • Perception of the health problem and appraisal of benefits and barriers of adopting health behavior are central to a decision to change

Question 29

What are the 5 aspects that are the basis of the decision to change in the health belief model?

Answer 29

Decision to change (or not) depends on how the client perceives: - Severity of potential condition or disease (perceived threat) - Susceptibility to that condition or disease (perceived threat) - Benefits of taking representative action (outcome expectation) - Perceived barriers to taking that action (most powerful) (outcome expectation) - Ability to make the required changes (self-efficacy) - Cues to action

Question 30

Readiness to action is based on the following beliefs or convictions in the health belief model:

Answer 30

* The threat to my health is serious * I perceive that the benefits of the recommended action outweigh the barriers or costs * I am confident that I can carry out the action successfully * Cues to action are present to remind me to take action

Question 31

Name an example of a project using the health belief model.

Answer 31

Low fat eating for Americans project (LEAN)

Question 32

What is the social cognitive theory?

Answer 32

A relationship exists between… • Behavior • Cognitions and personal factors • External environment Change is affected by a combination of these Theory goes well beyond individual factors to include environmental and social factors • Proposes that behavior is the result of personal, behavioral and environment factors that influence each other o Personal factors: people thoughts and feelings o Behavioral factors: food, nutrition and health related knowledge and skills o Environmental factors: factors external to the individual such as physical activity and social environments

Question 33

Name examples for each of the 3 categories of factors influencing behaviour according to the social cognitive theory

Answer 33

Personal/cognitive factors: Knowledge, expectations, attitudes Behavioural factors: Skills, practice, S-E Environmental factors: Social norms, access in the community, influence on others and environment e.g. - Social networks - Media - Social support, social structure of the family (approval of spouse? Peers? Etc.) - Cultural practices - Worksite - Food production and marketing - Healthy food accessibility - Means to be physically active

Question 34

Explain the reasoned action and planned behaviour theory

Answer 34

* People’s behavior is determined by their intentions which in turn are influenced by attitudes, social norms and perception of control over the behavior * This theory assumes that people make decisions in a reasonable manner * People are more likely to engage in a behavior if they intend to do so

Question 35

Explain the three factors that influence the intention to act/change in the reasoned action and planned behaviour theory

Answer 35

Social-psychological approach to understanding and predicting determinants of health behavior. Behavior is determined by the intention to act/change, which is determined by three major factors: 1. Attitude towards the behaviour - Beliefs about outcomes - Beliefs about the value of the outcome 2. Influence of social environment - What other people think - Motivation to comply with opinions of others 3. Perceived behavioral control over - Opportunities , resources, skills * I believe that taking this action will lead to outcomes I desire (attitude) * I perceive that the positive outcomes of taking this action outweigh the negative outcomes (attitude) * I have positive feelings about taking this action, and taking action will make me feel good about myself (attitude) * People important to me think that I should take this action and their opinions are important to me (social environment) * I am confident that I can carry out the action, despite difficulties (self-efficacy)

Question 36

Explain the transtheoretical model

Answer 36

Stages of change (Prochaska) • From a large comparison of behavior modification theories, showing that change is realized through a series of stages. • An on-going process, not an event, is cyclical • Is a model of behavior change, not a model predicting behavior • Based on the assumption that individuals have varying levels of motivation or readiness to change. • The idea behind this is that behavior change does not happen in one step

Question 37

Why is the transtheoretical model used in counseling?

Answer 37

Serves 2 purposes for us, as counselors: o Helps understand to process of behaviour change o Helps to develop and select effective intervention strategies

Question 38

Based on the transtheoretical model, what are the 2 mediators to change?

Answer 38

``` Decisional balance (pros and cons) Self-efficacy ```

Question 39

Based on the transtheoretical model, what are the 4 barriers to behaviour change?

Answer 39

1. Lack of motivation 2. Lack of support 3. Past failures 4. Unrealistic goals

Question 40

Explain the pre-contemplation stage of change.

Answer 40

- Ignoring the problem exists - Consciously intending not to change - Do not see a problem: denies having a problem - Stage of resistance, reluctance - Makes excuses (“yes but” syndrome) - Blames other people for the problem - Feeling hopeless after attempting to change (past failures) - May be resigned - Also included in this category are those who have tried and failed and no longer want to think about it Cons > Pros

Question 41

What should be done by the counselors in the precontemplation stage?

Answer 41

- Empathic and sensitive listening encouraging clients to examine their situation and its consequences can be very helpful - confrontation is NOT the remedy for denial Counselors can: • Provide information • Offer feedback • Encourage reflection

Question 42

What are the counseling goals for the people in the pre-contemplation stage of change?

Answer 42

* Increase awareness of the need for change * Personalize information on risks and benefits * Help patient develop a reason for changing (make them reflect on it) * Validate the patient’s experience * Encourage further self-exploration * Leave the door open for future conversations

Question 43

Explain the contemplation stage of change.

Answer 43

- “Sitting on the fence” - Considering a change but not right away (change expected in the next 6 months but not in the next month) - Knows behavior is a problem: not ready yet - The most common stage for clients to come to a P.Dt. for assistance in changing - Ambivalence re: consequences of behavior change (not as resistant as pre-contemplation, but still ambivalent) - Considering change but rejecting it Perception that long-term health benefits do not compensate for short-term real or perceived costs • A lot of perceived barriers (unacceptable tastes, economic constraints, inconvenience) Cons > Pros, but more aware of pros

Question 44

What should be done by the counselors in the contemplation stage?

Answer 44

* As counselors, assist them in thinking through the risks of the behavior and potential benefits of change and to instill hope that change is possible * Clients at this stage need motivational activities rather than action-oriented, behavior change strategies * Clients may be burned out from previous unsuccessful attempts at change * Clients lack self-esteem and believe that they do not have the skills, capacity or energy to change * Clients may be open to new information as they self- assess their problems and advantages/disadvantages of change

Question 45

What are the counseling goals for the people in the contemplation stage of change?

Answer 45

* Remove ambivalence to engage in the change process * Validate the patient’s experience * Clarify the patient’s perceptions of the pros and cons of attempted weight loss * Encourage further self-exploration * Leave the door open for moving to preparation

Question 46

Explain the preparation stage of change.

Answer 46

- “Testing the waters” New year’s resolutions is a good example! - Some ambivalence still present… - “I’m going to do it in the next weeks” - Getting ready to make a change soon - Stage with window of opportunity - Feeling that taking action is important - Might have started a few changes already (e.g. took an appt with you, bought a gym membership…) - Might have taken a few steps to prepare for change such as making an apt with a dietitian, inquiring about a walking club) - When advantages outweigh disadvantages Pros > Cons

Question 47

What should be done by the counselors in the preparation stage?

Answer 47

- Counselors need to sustain the energy for change throughout support, encouragement and empathic caring. - Client in this stage might be willing to try a new recipe or to taste some new foods - Assist them to develop concrete goals and action plan strategies - -> Goal setting starts in preparation

Question 48

What are the counseling goals for the people in the preparation stage of change?

Answer 48

* Develop concrete strategies for action * Praise the decision to change behavior * Prioritize behavior change opportunities * Identify and assist in problem solving re: obstacles * Encourage small initial steps * Encourage identification of social supports

Question 49

Explain the action stage of change.

Answer 49

- “Go for it” - Has taken steps (< 6 months) towards making a change - Change is initiated - Only 15% of clients initially seen will be in that phase (most are in contemplation phase!) - Clients may miss their old lifestyle and have conflicting feelings about the change

Question 50

What should be done by the counselors in the action stage?

Answer 50

- Counselors can remind clients when encountering obstacles of previously developed contingency plans - Action-oriented strategies are very helpful - Clients are actively involved in the change process - Clients are working on the goals and implementing the plans developed in the preparation stage

Question 51

What are the counseling goals for the people in the action stage of change?

Answer 51

* Implement change and sustain momentum (important to check with the client if he has discovered parts of the change plan that needs revision) * Increase self-efficacy for dealing with obstacles * Combat feelings of loss and reiterate long-term benefits

Question 52

Explain the maintenance stage of change.

Answer 52

- “Steady as she goes” - “I’ve done it. I need to keep doing it” - Continued commitment to sustain new behavior (> 6 months) - Has made a change and has been successfully working on it for past 6 months to 5 years - Clients might still be insecure and nervous about being able to maintain changes

Question 53

What should be done by the counselors in the maintenance stage?

Answer 53

- Client need to work actively on modifying the environment to maintain the changed behavior and prevent relapse (remove triggers for relapse)

Question 54

What are the counseling goals for the people in the maintenance stage of change?

Answer 54

• Sustain change and accept relapses (develop new strategies for dealing with stress points and triggers)

Question 55

What is a relapse? When does it usually occur?

Answer 55

- The most common time to occur is in the first 3 to 6 months - Has returned to old behavior - Accompanied by feelings of failure & self-doubt - Client succumbs to the pressure to resume their old ways of behaving - It’s important to discuss lapses and relapses early with our clients

Question 56

What are the counseling goals for the people in the relapse stage?

Answer 56

1. Counselors can help clients accept 2. Counselors can help clients identify the decision or action which got them into the high-risk situation (unexpected temptations, personal stress, triggers, letting down one’s guards, sabotage by others....) 3. Recovery requires re-learning skills from earlier stages and learning new skills to “get back on the horse”

Question 57

Explain the termination stage of change.

Answer 57

Individual has no temptation to return to his previous unhealthy behavior, no longer succumb to any temptation and feel total self-efficacy.

Question 58

Summarize the 6 stages of change.

Answer 58

1. Precontemplation 2. Contemplation 3. Preparation 4. Action 5. Maintenance 6. Relapse/Termination

Question 59

Define counseling

Answer 59

A time-limited relationship in which counselors help clients increase their ability to deal with the demands of life

Question 60

What are the 3 variables of counseling?

Answer 60

1. The needs and wants of the client 2. The mandate of the counseling setting 3. The expertise and competence of the counselor

Question 61

Differentiate the immediate from the long-term goal of counseling

Answer 61

Immediate goal: To provide assistance so that clients can gain control over their problems Long-term goals: Restore or develop client’s ability to cope with the changing demands of their lives --> EMPOWERMENT

Question 62

Name the 10 most common counseling errors

Answer 62

1. Rigidity and use of a “one size fits all” approach 2. Insufficient attention to the counselor-client relationship 3. Advice giving 4. Absence of core conditions (empathy, attending, genuineness...) 5. Missing the opportunities offered by paying attention to the non-verbal channel 6. Loss of objectivity and judgmental responses 7. Pacing problems (too fast, too slow, inappropriate timing of responses) 8. Inappropriate use of self-disclosure (too much, too little, poorly timed) 9. Rescuing, false reassurance, minimizing problems 10. Cultural insensitivity

Question 63

What are the 4 main skills for counseling?

Answer 63

1. Relationship building skills (empathy, active listening, questioning, sustaining the relationship) 2. Exploring & probing skills (active listening, attending) 3. Empowering skills (identifying resources, support systems, past successes and failures, defining problems as opportunities) 4. Challenging skills (confronting, setting limits)

Question 64

Name 3 ways in which technology can be used in counseling

Answer 64

1. Recording 2. Reminders 3. Sharing resources

Question 65

Does technology-based programs hinder weight loss?

Answer 65

One of the consistent findings was that adding a technology-based program did not hinder weight loss.

Question 66

Name as many basic counseling responses as possible.

Answer 66

- Attending (active listening) - Reflection (empathizing) - Legitimation (affirmation - Respect - Personal support - Partnership - Mirroring - Paraphrasing (summarizing) - Giving feedback - Questioning - Clarifying (probing) - Noting a discrepancy (confrontation) - Directing (instructions) - Advice - Allowing silence - Self-disclosing

Question 67

What is attending as a counseling response?

Answer 67

* Is active listening * Create an ambiance to facilitate meaningful communication * Involves giving individual attention to the client * Many attending behaviors are non-verbal * Engage, build a relationship with the client

Question 68

What can be done to increase the attending response from the counselor?

Answer 68

``` Reorganize surroundings - Try not to have a desk between you and the client Sit down to enable eye contact Face client squarely Adopt an open posture Lean toward client slightly Maintain good eye contact Try to be relaxed Focus on client not self Pay attention to a client’s vocal style (speech, rate, volume, tone…) should indicate concern Gestures Barriers (Time constraints, Temperature, Noise) ```

Question 69

What is the... - Intimate distance zone? - Personal distance zone? - Social distance zone? - Public distance zone?

Answer 69

- Intimate distance zone (private exchange, intimate thoughts and feelings) o 0.5 meter or 2 feet - Personal distance zone (less intense exchange with friends and family) o 0.5 – 1.0 meter or 2 – 4 feet - Social distance (impersonal meetings and social contacts) o 1.0-3.5 meters or 4 – 12 feet - Public distance (giving speech or lecture, casual exchanges) o 3.5 meters or 12 feet

Question 70

How many words does one think in a minute? What should you be thinking about during counseling?

Answer 70

Thinking: 600-800 words/min - Thinking about what the speaker says - Summarizing key points - Listening for feelings, not only content - Looking for consistency/inconsistency *Talking: 100-200 words/min

Question 71

What is reflecting as a counseling response? Why is it used for?

Answer 71

* Rephrasing the affective (feelings) part of a message * Brings the client to deeper and deeper levels of self-disclosure * One of the most challenging skill to develop * The feeling component of a message is often hidden because disclosure of feelings is bound by cultural and family rules * Used by helpers to stimulate deeper exploration of the facts, feelings and meanings (includes emotions) in the client’s presentations of the problem * Forges empathetic bond between the client and the helper (client senses that someone has taken time to understand) * Effective listening uses statements rather than questions * When reflecting your client’s feeling, understate what he or she said.

Question 72

What are the 4 steps in reflecting?

Answer 72

1. Correctly identify the feeling being expressed (anger, fear, conflict, sadness, happiness) --> not too early 2. Reflect the feeling you have identified to the client 3. Match the intensity of your response to the level of feeling expressed by the client 4. Respond to the feeling of your client: not the feeling of others

Question 73

What are the formulas to reflect a feeling and a meaning?

Answer 73

Formula to reflect a feeling: You felt ____ (emotion) when ____ (event or thought) Formula to reflect a meaning: You felt ____ (emotion) because ____ (meaning) OR "it sounds like.../seems like..."

Question 74

What is legitimation (affirming) as a counseling response? Why is it used for?

Answer 74

* It’s a type of reflection * A statement that affirm some strength and efforts shown by the client * Points out a job well done * Avoid using the “I” word and highlight non-problem areas * Encourages a client who lacks initiative/self-confidence * Positive thoughts, words and actions as a way to support positive change

Question 75

What are common difficulties in reflecting feelings/meaning?

Answer 75

- Having trouble separating their own feelings from the experience of the client - Deciding on which of several feelings the client is experiencing to reflect - Stating the client’s feelings too definitely (e.g. you are obviously angry) - Feeling uncomfortable when the client expresses intense feelings (ex: when clients cry, helpers may want to take away their sadness and pain rather than accepting the feeling and being with the client in a difficult moment)

Question 76

What is mirroring as a counseling response? Why is it used for?

Answer 76

(Parroting, echoing) • Repeating what you have heard with a few words changed • Do not overdo this response • Allows counselor to let client know that you are listening and encourages the person to keep talking and exploring • Could choose to echo back key words or a key word My diet is a disaster” --> “a disaster.” Or “what do you mean by a disaster?”

Question 77

What is paraphrasing as a counseling response?

Answer 77

* Reflective skill on content and thoughts * Rephrasing on the content of what the client said and meant * Not a word for word reiteration * Done non-judgmentally * Stating thoughts from a different angle * Can summarize prior statements or several statements of a conversation

Question 78

Why is paraphrasing used?

Answer 78

* Lets the client know that you are listening * Encourages client to continue talking * To interrupt excessive rambling * Restating key messages to the client * Confirms understanding and checks assumptions * You won’t find yourself arguing, when you basically agree. * The other person will realize you are trying to understand their side and will be more willing to listen to you. * Gives client the opportunity to correct inaccuracies

Question 79

Name a few phrase or sentence stems to introduce paraphrase responses

Answer 79

* It seems like * It appears as though * From my perspective * As I see it * It looks like * As I hear it * Put a different way * The picture I get is * What you’re saying is * I hear you saying * You’re telling me that * From my standpoint

Question 80

What are the 2 steps in paraphrasing?

Answer 80

1. Listen carefully to the client’s story feeding back to the client in a condensed non-judgmental version of the facts and thoughts 2. Find the important information in a large volume of client material and repeat it in a succinct summary

Question 81

Differentiate paraphrasing from summarizing

Answer 81

Paraphrasing an extended interaction is referred to as summarizing

Question 82

What is included in summarizing?

Answer 82

* Review what has occurred during the session * Include a summary of the issues * Identify strengths & efforts you have heard * Restate the goals * Could use a partnership statement * Plan for next counseling encounter

Question 83

What is clarifying (probing) as a counseling response?

Answer 83

* To encourage more elaboration from the client * To check out accuracy and what you heard the client say * To clear up vague and confusing messages * Permits the counselor to be clear about the client’s feelings and experiences * Often use a question * Often use “why” after an ambiguous message

Question 84

What is directing (instructions) as a counseling response?

Answer 84

• Telling a client exactly what needs to be done, instructions E.f. fluid intake in kidney disease, carb counting in diabetes, etc.

Question 85

When and how should advice be given in counseling?

Answer 85

* Do it scarcely * Providing possible solutions for problems when there is a clear understanding of the problem * Should be non-judgemental * Should identify the problem * Should explain the need to change * Don’t use too much, however, none might leave the client confused

Question 86

When should a counselor NOT interrupt their client?

Answer 86

- When the client is exploring reasons to make changes (change talk – Client from contemplation --> preparation phase --> action phase) - When a client is expressing strong feelings

Question 87

When should a counselor interrupt their client?

Answer 87

- When the client is wondering off topic | - When you have heard some change talk and you want to summarize

Question 88

How should the counselor interrupt a client if needs be?

Answer 88

- With respect - Could start with the client’s name, single words - With an apology - With an offer: “I have a thought or an idea” - Wait for permission to provide idea or advice

Question 89

When should a silence be used in counseling?

Answer 89

o Client need space for internal reflection and self-analysis o May be after an open-ended question o Used after an emotional outburst (disclose of feelings, crying) o After a complex reflection that gets the clients attention o Used after complex instructions have been provided when client needs to process information • After a client has realized something important or has insight

Question 90

When can silence be negative in counseling?

Answer 90

- Tension is high - Your client is confused or anxious - When no empathy is experienced

Question 91

How should a counselor break the silence if nothing else is said?

Answer 91

o Repeat last phrase or sentence said with a questioning tone or ask o What the client was thinking about during the silence o Ask client was his/her thoughts are or what his/her response is to that?

Question 92

Differentiate the old counseling method "nutrition education" from "Nutrition therapy" (new)

Answer 92

- Time constraints vs. more time - Gives dos and donts vs fosters choice among options - no relationship vs relationship - Limited f/u vs. open-ended with time - Strictly diet-oriented vs. explores personal issues - Less opportunity for measuring adherence vs. evaluate adherence and make adjustments - client is dependant vs. independance promoted - Less interdisciplinary op vs team approach emphasized

Question 93

Name advantages of home counseling

Answer 93

o The most obvious is that home bound patients can’t come in to your office o Some starting dietitians do so as it permits them to avoid the overhead costs of maintaining an office o Gives you the opportunity to look at the environment in which the client does much of his food storage, preparation and eating (look into fridge, pantry, is there a table for family meals, cooking utensils...) o permits you to better assess the client’s economic resources (more evident in their home) o you can do label reading with items they already have, discuss portion sizes using their won measuring cups, plates, glasses, bowls...

Question 94

Name disadvantages of home counseling

Answer 94

o In someone’s home, you can never be certain that you will have an uninterrupted session (phones, tv, family members...) o It can be harder to adhere to time limits o You don’t have access to all of your resources (handouts, Food models....) o Take up more of your time (travel time, finding parking, small talk at the beginning, being offered coffee…) o Safety: you don’t know what you are walking into

Question 95

What does home counseling do to the helping relationship?

Answer 95

o There is a tendency for the visit to feel a bit more social and less professional o The client is in the role of a host o More difficult to maintain control of the session when you are in the client’s space o Some dietitians like to use a clock to time their visit to adhere to time limits o You need to discuss ahead of time with your client your role, what you expect to accomplish, what you will need from him, the time of the visit, who will be there…

Question 96

What are the 4 phases of the counseling/interview process?

Answer 96

1. Involving phase 2. Exploration phase 3. Resolving phase 4. Closing phase

Question 97

Explain the involving phase of counseling

Answer 97

- Greetings and introductions - Identify client’s long-term behaviour change objectives - Explain rationale for recommended diet - Explain counseling process - Set agenda - Objectives are to establish rapport, trust to communicate an ability to help

Question 98

Explain the exploration phase of counseling

Answer 98

- Assess food behaviour, activity patterns and past behavior change attempts - Explore problems, skills and resources - Give non-judgmental feedback - Elicit client response - Assess readiness to change - Objectives are to provide information, show acceptance, learn nature of problems and strengths, promote self-exploration by the client and help the client to evaluate the situation

Question 99

Explain the resolving phase of counseling

Answer 99

- Tailor the intervention to the client’s motivational level - Objectives are to help the client make decisions about behavior change, indicate that the client is the best judge of what will work

Question 100

Explain the closing phase of counseling

Answer 100

- Support self-efficacy - Review issues and strengths - Restate goals - Express appreciation - Arrange follow-up - The objectives are to provide support and provide closure

Question 101

What is the definition of life skills?

Answer 101

There is no universally accepted definition of life skills. | Different organizations attach different meanings to the term.

Question 102

According to the International Bureau of Education (IBE) what are the 4 pillars of learning? and what defines life skills?

Answer 102

1. Learning to know 2. Learning to do 3. Learning to be 4. Learning to live together and defines life skills as personal management and social skills which are necessary for adequate functioning on an independent basis.

Question 103

What are the 4 H quadrants of the life skill model?

Answer 103

Head, Hearth, Hands, Health

Question 104

What are the 2 categories included in the HEAD quadrant?

Answer 104

Managing & thinking

Question 105

What are the 2 categories included in the HEART quadrant?

Answer 105

Relating & caring

Question 106

What are the 2 categories included in the HANDS quadrant?

Answer 106

Giving & working

Question 107

What are the 2 categories included in the HEALTH quadrant?

Answer 107

Living & being

Question 108

Explain the aspects included in the "managing" category of the life skills model

Answer 108

``` o Resiliency - Being accepting, stop asking questions or looking for answers o Keeping records - Keep things up to date o Wide use of resources o Planning/organizing o Goal setting ```

Question 109

Explain the aspects included in the "thinking" category of the life skills model

Answer 109

``` o Service learning - Give back to profession o Critical thinking o Problem solving o Decision making o Learning to learn ```

Question 110

Explain the aspects included in the "relating" category of the life skills model

Answer 110

``` o Communication o Cooperation o Social skills o Conflict resolution o Accepting differences - Culturally competent ```

Question 111

Explain the aspects included in the "caring" category of the life skills model

Answer 111

o Nurturing relationships o Sharing o Empathy o Concern for others

Question 112

Explain the aspects included in the "working" category of the life skills model

Answer 112

o Marketable skills o Teamwork o Self-motivation

Question 113

Explain the aspects included in the "giving" category of the life skills model

Answer 113

o Community service volunteering o Leadership o Responsible citizenship o Contributions to group efforts

Question 114

Explain the aspects included in the "living" category of the life skills model

Answer 114

o Healthy lifestyle choices o Stress management o Disease prevention o Personal safety

Question 115

Explain the aspects included in the "being" category of the life skills model

Answer 115

o Self-esteem o Self-responsibility o Character o Managing feelings - Learn to deal with your own emotions and influence on behaviour o Self-discipline - Stress-management, sleep patterns etc.

Question 116

Name many actions towards learning life skills

Answer 116

1. Assume responsibility for own mistakes 2. Keep up best practices 3. Adapt to different situations 4. Validate information 5. Solve problems 6. Take a stand 7. Anticipate the results of own actions 8. Respect the rules 9. Appreciate the ideas of others (important to work with others) 10. Be respectful 11. React depending on the context 12. Demonstrate perseverance 13. Share Information 14. Demonstrate compliance 15. Give some leeway 16. Demonstrate ethical judgment 17. Manage difficult situations 18. Work with integrity 19. Be caring 20. Put the effort 21. Work with pride 22. Have good manners 23. Use diplomacy 24. Accept criticism 25. Be self-confident 26. Be punctual 27. Be authentic 28. Be trustworthy

Question 117

What are the personal skills/competences for how we manage ourselves?

Answer 117

Self-awareness o Emotional awareness o Accurate self-assessment o Self-confidence ``` Self-regulation o Self-control o Trustworthiness o Conscientiousness o Adaptability o Innovation ``` ``` Motivation o Achievement drive o Commitment o Initiative o Optimism ```

Question 118

What are the personal skills/competences for how we handle relationships with others?

Answer 118

``` Empathy o Understanding others o Developing others o Service orientation o Leveraging diversity o Political awareness ``` ``` Social skills o Influence o Communication o Conflict management o Leadership o Change catalyst o Building bonds o Collaboration and cooperation o Team capabilities ```

Question 119

Describe the cognitive behavioral therapy and its key concepts.

Answer 119

Started around the 1950s Started being used more around 2008 More often used in mental disorders, can be use in weight loss settings but less. Key concepts: 1. Distinguish between thoughts and feelings • Become aware of ways in which their thoughts affect their feelings • Analyze the validity of their thoughts • Develop skills to interrupt and change harmful thinking 2. Challenge pattern of thinking • Harmful self-monologues should be identified, eliminated and replaced with productive self-talk • Actions and feelings are modified by influencing a person’s thinking patterns 3. Stress Management (relaxation training, meditation) Behavior is learned so it can be unlearned; irrational ideas are self-defeating; focus is on changing the environment.

Question 120

According to the CBT, what is the birthplace of emotion, self-esteem and behaviour?

Answer 120

Thoughts o Negative/unhelpful thoughts: emotions, feelings and behaviours are all linked and affected • Positive (helpful) thinking creates an “I can do it” attitude which leads to a greater willingness to embrace new challenges and take appropriate risks. • Negative (unhelpful) thinking patterns create distress and interfere with one’s overall sense of well-being

Question 121

How can CBT affect eating?

Answer 121

- Identify and remove cues o Stimuli that affect food behaviour (smelling or seeing food, watching television, studying, boredom, social events, stress, sad…) - Provide substitutions

Question 122

Describe the factors involved in the CBT.

Answer 122

``` Situation/Environment I V Thoughts / . I Actions/behaviour --> Feelings ```

Question 123

What are the things a counselor can do to help a client changing a behaviour based on the CBT?

Answer 123

* Helping clients recognize thinking patterns in particular those that are unhelpful. * Helping clients modify thinking patterns. * Assisting clients to develop actions, plans and strategies to modify behaviour. * Behaviour persists because clients are locked into unhelpful ways of thinking about their problems or solutions. * Thinking patterns that drive feelings and behaviors are frequently outside a client’s awareness. * A person’s thinking might be driven by assumptions or faulty beliefs. * CBT is designed to help clients develop conscious awareness of their thinking patterns then critically examine their validity and usefulness. * Then, clients learn strategies for interrupting unhelpful thinking while increasing helpful thinking and behaviour.

Question 124

What is trans-professional practice?

Answer 124

When a practitioner acquires some of the skills of another profession, not to compete but to increase the efficiency and effectiveness of their intervention and improve the outcome for the client

Question 125

What is eating influenced by?

Answer 125

• Your environment (social, physical, time constraints) • Your body (satiety cues) • Your learned behaviours (conditioned fast eaters) THOUGHTS (mouse story)

Question 126

When and where is CBT used?

Answer 126

- More conducive to outpatient settings, where time permits - Hospital setting is not conducive - In one-on-one or group counselling - May be offered in collaboration with other health care professionals - May depend on organization where dietitian is working

Question 127

What are the steps to use CBT in a counseling setting?

Answer 127

1) Identify problematic behaviour 2) Visualize the situation and tune into thoughts 3) Reflect on the routes the thoughts take 4) Consider alternative thoughts that could re-route the thoughts to arrive at a different behaviour

Question 128

Describe mindfulness

Answer 128

- Has roots in Buddhist and other contemplative traditions - Defined as: “the state of being attentive to and aware of what is taking place in the present”, the here and now - Involves a way of seeing, feeling, knowing, focused on the present and that facilitates greater centeredness on focus and awareness (Kabat-Zinh, 2012) - Means having the client get in touch with experiences as they occur moment to moment - Without awareness, clients are more likely to behave compulsively or automatically - Mindfulness permits attentiveness to feelings of hunger and fullness and help bring a balanced approach to eating - Mindfulness is a method of encouraging clients to use their inner wisdom to find joyfulness in the preparation and consumption of food

Question 129

Name examples of mindless eating

Answer 129

 Eating until you are too full and then feeling guilty  Emotional eating – eating when you are bored, stressed or anxious rather than hungry  Grazing on food without really tasting it  Mindlessly munching on snacks while zoned out in front of the TV  Eating a meal at the same time each day whether you are hungry or not  Skipping meals, not paying attention to your hunger signals

Question 130

Name some clues to indicate that a client is not eating mindfully

Answer 130

* Not remembering what was eaten * Binge eating * Guilt over eating (good or bad foods) * Wanting to be told what to eat * Rapid eating

Question 131

What is mindful eating?

Answer 131

“Mindful eating is not a diet. There are no menus or recipes. It is being more aware of your eating habits, the sensations you experience when you eat, and the thoughts and emotions that you have about food. It is more about how you eat than what you eat”. - Is being aware without being judged or criticized - Is deliberately paying attention to what is happening inside your body and in your environment - Promotes balance, choice, wisdom and acceptance of what is - Is allowing yourself to become aware of the positive and nurturing opportunities that are available through food preparation and consumption by respecting your own inner wisdom - Is not difficult, but practice is essential - With practice, mindfulness cultivates the possibility of freeing yourself of habitual patterns of feeling and acting - Involves listening to hunger, fullness, taste, satiety cues - Slowing down the pace of eating - Eating away from distractions (focus on eating) - Becoming aware of the body’s hunger & fullness inner cues (satiety) - Utilizing these cues to guide the decision to begin and end eating - Acknowledging responses to foods - Be in the present - Choosing to eat foods that is pleasing and nourishing by using all senses of eating - Eat non-judgmentally

Question 132

Name and explain the 5 principles of mindful eating

Answer 132

1. Awareness - Tasting vs. mindless munching 2. Savor - Notice texture, aroma, flavor - Is it crunchy, sweet, salty, smooth, spicy? 3. Observe - Notice your body (rumbling stomach, low energy, stressed out, satisfied, full, empty) 4. In-the-moment - Be fully present, turn off TV, sit down - When you eat, just eat 5. Non-judgement - Speak mindfully and compassionately - Notice when “shoulds”, rigid rules or guilt pop into your mind

Question 133

How can mindful eating be incorporated to the precontemplation stage of change?

Answer 133

“So you tend to ignore your appetite and wait until its lunchtime.” - Invite attention to appetite, satiety, taste, texture... No intent to change; go for awareness and self-reflection

Question 134

How can mindful eating be incorporated to the contemplation stage of change?

Answer 134

• Some awareness of mindless eating • Client may have little idea of other options “Do you know what mindful eating is? “Would you like to hear more about it?” “What is your belief about what would happen if you mostly ate when you were hungry and stopped when you were satisfied?” With a client in these earlier stages, you will likely need to let go of your focus on mindful eating. Stay client-centered.

Question 135

How can mindful eating be incorporated to the preparation stage of change?

Answer 135

* Client wants to eat more mindfully * Believes that if eat mindfully most of the time, will feel better * Client does not need much persuasion * Client will notice some triggers to mindless eating

Question 136

How can mindful eating be incorporated to the action stage of change?

Answer 136

* Client doing mindful eating and bringing observations back to you * May ask for ideas for more changes to make * Willing to try out * In this phase, you are the consultant, you help the client brainstorm about new ideas * Encourage that normal eating includes some mindless eating

Question 137

How can mindful eating be incorporated to the maintenance stage of change?

Answer 137

* Client eating mostly mindfully * Client has ways to cope with most triggers to eat mindlessly * Be available for relapse if necessary

Question 138

What influences the amount of food we eat?

Answer 138

``` • The eating setting • Ambiance • Lighting • Eating with others • The menu The counselor has to help the client identify potential distracting situations ```

Question 139

What 4 common things do people do while eating?

Answer 139

1. Watch TV 2. Engage in conversation 3. Read a book 4. Listen to music

Question 140

What are the 10 principles of intuitive eating?

Answer 140

1. Reject the diet mentality 2. Honor your hunger Keep your body biologically fed Limits cravings and overeating 3. Challenge the food police 4. Make peace with food • no “good” & “bad” foods 5. Respect your fullness 6. Discover the satisfaction factor • Food is a pleasure. 7. Honor your feelings without using food 8. Respect your body • Accepting your genetic blueprint 9. Exercise – feel the difference • Get active on everyday life, do not need to do very big workouts at the gym! 10. Honor your health

Question 141

Name 3 strategies to evaluate hunger.

Answer 141

``` • Tuning into hunger • What are you hungry for? 3 different types of hunger:  Stomach hunger (physically hungry)  Mouth hunger (craving a specific taste or texture)  Heart hunger (emotional need, or learned behaviour) • Establish hunger/fullness cues o Starving o Ravenous o Hungry o Slightly hungry o Satisfied o Slightly full o Full o Slightly overfull o Overfull o Stuffed ```

Question 142

Name 4 similarities between intuitive and mindful eating

Answer 142

Non-restrictive Internally-driven Weight neutral Encourages a healthy relationship with food and body

Question 143

differentiate intuitive from mindful eating

Answer 143

Intuitive eating focuses on: - Eating for physical rather than emotional reasons - Rely on internal hunger and satiety cues - Unconditional permission to eat - Honoring one's health, or practicing "gentle nutrition" Mindful eating is similar but includes: - Non judgemental awareness of physical and emotional sensations while eating ot in a food-related environment

Question 144

What is motivational interviewing and why was it first developed?

Answer 144

- Developed by William Miller in 1983 (relatively new) - Later refined by Miller and Stephan Rollnick in 1991 - Used to address and intervene with problem drinkers Ultimate goal: Get clients over resistance and ambivalence --> change The most recent definition as defined by their founders Miller and Rollnick (2013): “…a collaborative, person-centered form of guiding to elicit and strengthen motivation for change” - MI is a particular kind of conversation about change between the counselor and the client - MI is collaborative (person-centered, partnership, honors autonomy, not expert-recipient) - MI is evocative (seeks to call forth the person’s own motivation and commitment) It’s designed to pay particular attention to the language of change, to strengthen an individual’s motivation for and movement towards a specific goal by eliciting and exploring the person’s own argument for change.

Question 145

Name and explain 3 techniques that were used when dietitians played the roles of educators.

Answer 145

Confrontation: Counseling involves over-riding the client’s impaired perspectives by imposing awareness and acceptance of « reality » that the client cannot see or will not admit. Education: The client is presumed to lack key knowledge, insight, and/or skills that are necessary for change to occur. The counselor seeks to address these deficits by providing the requisite enlightenment. Authority: The counselor tells the client what he or she should do.

Question 146

How is motivation viewed in MI?

Answer 146

• With MI, motivation is not viewed as a personality trait or a defensive mechanism • Motivation originates from internal beliefs and values (from within) - Has to come from the client, otherwise change will not occur • It’s considered a state of readiness to change that can alter and be influenced by others

Question 147

What is the ultimate goal of MI?

Answer 147

Help clients move through the Stages of change, no matter where they are now

Question 148

What are the 3 basic elements of MI?

Answer 148

1. COLLABORATION between therapist and client. Counseling involves a partnership that honors the client’s expertise and perspectives. The counselor provides an atmosphere that is conducive rather than coercive to change. 2. EVOKING/EVOCATION (or drawing out) the client’s ideas about change rather than imposing them. The resources and motivation for change are presumed to reside within the client. Intrinsic motivation for change is enhanced by drawing on the client’s own perceptions, goals, and values. 3. AUTONOMY (empathizing it vs authority)The counselor affirms the client’s right and capacity for self-direction and facilitates informed choices.

Question 149

What are the 4 distinct principles that guide the practice of MI?

Answer 149

1. Express empathy (what I feel AS you) 2. Support self-efficacy (Help clients identify past successes) 3. Roll with resistance (Avoid arguing, no power struggles. The MI value of having the client define the problem and develop their own solution leaves little for the client to “resist”) 4. Develop discrepancy (MI works to develop this by helping clients examine discrepancies between their current circumstances (behaviors and their values and future goals. Client has to be the one presenting its arguments towards change)

Question 150

What are the 6 key communication skills in MI?

Answer 150

1. Open-ended questions 2. Affirmations 3. Reflections 4. Summarizing 5. Information exchange 6. Empathy

Question 151

How do open-ended questions contribute towards the goal of MI?

Answer 151

Asking questions, the answer to which is change talk. Includes scaling; and why a 5 and not a 2?

Question 152

How do affirmations contribute towards the goal of MI?

Answer 152

o Affirms client’s successes, positive things and change talk. o Need to be done genuinely, respectfully, individualized, situationally or behaviourally specific

Question 153

How do reflections contribute towards the goal of MI? Differentiate a simple from a complex reflection

Answer 153

o Simple or complex reflections  Simple: Reflect back to the person what they have said to you  Complex: Hypothesis about what the person is feeling or what they are meaning and propose it back to them

Question 154

What is the objective of favoring change talk?

Answer 154

* The objective of change talk is to resolve ambivalence by providing opportunities and encouragement for the client rather than the counselor making arguments for change * When the client expresses the need to change or the reasons why change is necessary, the balance of indecision begins to shift toward taking action

Question 155

What are the types of change talk?

Answer 155

``` DARN-CAT Desire Ability Reason Need Commitment Activation Taking steps ```

Question 156

Explain and give examples for the "desire" type of change talk

Answer 156

What they’d like to do differently, their preferences for change  “I want to…” (I want to get rid of this pain)  “I would like to…” (I would like to play more with my grandkids)  “I wish…” (I wish I could lose some weight) (Desire statements tell you about the person’s preferences either for change or for the status quo)

Question 157

Explain and give examples for the "ability" type of change talk

Answer 157

If they were to make a change, how would they do it? How confident are they to change? Statements about capability  “I could…” (I could probably take a walk before supper)  “I can….” (I can imagine making this change)  “I might be able to….” (I might be able to cut down a bit) (The ability-related change talk also signals motivational strength. “I definitely can” reflects much stronger confidence than “I probably could” or “I might be able to”.)

Question 158

Explain and give examples for the "reason" type of change talk

Answer 158

People’s specific arguments for change, what would be good about change?  “I would probably feel better if I……” (I’m sure I’d feel better if I exercised regularly.”  “I need to have more energy to play with my kids”  “This pain keeps me from playing the piano.”  “Quitting smoking would be good for my health.” (Change talk can express specific reasons, but reasons can occur along with desire verbs)

Question 159

Explain and give examples for the "need" type of change talk

Answer 159

What is important for them about change? Why does it matter? Often emotional reasons for change, based on the person’s values Statements about feeling obliged to change  “I ought to…” (I ought to make better food choices)  “I have to…” ((I must get some sleep)  “I really should….” (I really should get more exercise)

Question 160

Explain and give examples for the "commitment" type of change talk

Answer 160

The client’s statements of commitment to actual change Statements about the likelihood of change. When it comes to commitment the quintessential verb is will, but commitment has many forms. Some statements of strong commitment are: • “I promise……”, • “I will….” • “I intend to…” • “I am ready to….” But, don’t miss lower levels of commitment because they are steps along the way too- People signal an opening door with such statements as: “I will think about it”, “I’ll consider it”, “I plan to”, “I will try to”.

Question 161

Explain and give examples for the "taking steps" type of change talk

Answer 161

Statements about an action taken  “I actually went out and…..”  “This week I started……” You may encounter this particularly when you see patients repeatedly over time. These statements indicate the person has taken, even if haltingly, some step toward change. He or she has done something that moves him or her in the direction of change.  “I quit smoking for a week, but then started up again.”  “I walked up the stairs today instead of taking the elevator.”  “I went all last week without stopping by McDonalds.”

Question 162

What should be done by the counselor after a client has expressed "need" change talk?

Answer 162

Summarize what they said for the change talks up to now

Question 163

Name strategies to evoke change talk.

Answer 163

1. Ask evocative questions - Ask an open-ended question the answer to which is likely to be change talk 2. Explore decisional balance - Ask for pros and cons of both changing and staying the same 3. Good things/not so good things - Ask about the positive and negative of the target behavior 4. Ask for elaboration/examples - When a change talk theme emerges, ask for more details 5. Look back - Ask about a time before the change behavior emerged. Were things better, different? 6. Look forward - Ask what may happen if things continue as they are (status quo) 7. Query extremes - What are the worse things that might happen if you don’t’ make this change? What are the best things that might happen if you make this change? 8. Use scaling (importance and confidence) (0-10) 9. Explore goals and values - Ask what the person’s guiding values are? What do they want in life? 10. Come alongside - Explicitly side with the negative (status quo) side of ambivalence - You are a 6, why not a 2? • Asking evocative questions about: o Disadvantages of status quo o Advantages of change o Intention to change o Scaling questions o Exploring positive and negative consequences of status quo o Provoking extremes o Looking back to help client remember how things were before the current situation o Looking forward by asking clients to describe their hopes and goals for the future o Exploring goals o Helping clients understand their ambivalence to change

Question 164

Name some signs of readiness to change

Answer 164

• Increased change talk • Decreased sustain talk • Taking steps • Resolve Reached some solution - peaceful, relaxed, calm, unburdened, or settled o A kind of quietness settles – loss, tearfulness, or resignation • Questions about change • Envisioning The client begins to talk about how life might be after a change and what might be challenging in getting there.

Question 165

Name some signs of resistance

Answer 165

• “Yes but……” • “Well, I guess I could try” • Arguing, interrupting, ignoring, denying • Client returns for the next visit and has not done what you thought he agreed to • The client does not return for a scheduled visit • Body language looks like reluctance o Look at non-verbal signals

Question 166

Name and explain the 2 types of resistance

Answer 166

1. Sustain talk Client talking about themselves, their perception “My blood sugar isn’t a problem” “I really love to eat with the TV on” 2. Discord Client talking about us or our interactions “You don’t understand” “I won’t do that” (in response to one of your suggestions) “You can’t help me”

Question 167

Name some reasons why people are ambivalent

Answer 167

* Alternatives (status quo and change) are equally appealing * Neither course of action is appealing * Both alternatives have features that are both appealing/unappealing * Conflicted feelings (knowing what’s right but going the opposite direction: heart vs intent) * Fear of loss (e.g. smoking) * Not knowing what’s right (should I change or not?)

Question 168

What are the steps in the use of MI?

Answer 168

1. Assess stage of change - Explore values, goals, concerns, barriers, etc. via open-ended questions - Identify « change talk » phase 2. Adapt intervention to specific stage of change

Question 169

In MI, what should be done when a patient is in the pre-contemplation stage of change?

Answer 169

- Establish rapport (empathy!) - Make client understand that deciding to change must come from them (they are the one taking the ultimate decision to change behavior) - Assess if client knows consequences of status quo - Provide information, encourage them to get information from others - Promote client self-evaluation (why do they behave like they do? It’s a good way to explore concerns) Strategies: help client to inform themselves about consequences of their behavior + DO NOT argue for change

Question 170

In MI, what should be done when a patient is in the contemplation stage of change?

Answer 170

- Raise awareness of benefits of changing - Client has clear ambivalence: normalize it - Explore barriers and self-efficacy - Elicit/evoke change-talk Strategies: use decisional balance worksheet (pros and cons) + scaling of importance

Question 171

In MI, what should be done when a patient is in the preparation stage of change?

Answer 171

- Help client build a plan - Propose suggestions (ask for permission first) or reinforce clients’ propositions (« what have you considered doing? ») - Help client identify social support and potential barriers, as well as solutions for those Strategies: assess readiness through scaling + ask about past successes + make client define SMART goals

Question 172

In MI, what should be done when a patient is in the action stage of change?

Answer 172

- Support client through change - Reinforce long-term benefits, strengths, current successes (via affirmation) o Needs to be genuine and be done at an appropriate time Strategies: help client dealing with obstacles and finding resources (developing coping skills)

Question 173

In MI, what should be done when a patient is in the maintenance stage of change?

Answer 173

- Help clients staying on the way - Discuss about relapse prevention Strategies: Affirm success + Explore positive feelings/benefits they currently experience + reaffirm coping skills

Question 174

How is a decisional balance worksheet used in MI?

Answer 174

* Do not use in pre-contemplation * Ask client about pros and cons of both staying the same and changing * At the end, paraphrase while emphasizing on pros of changing and cons of staying the same * Client will want to change when he/she is at a level where they identify more pros about changing than pros about status quo

Question 175

In MI, what should be done when a patient is in the relapse stage of change?

Answer 175

- Make sure client is not only experiencing a lapse - Identify cause of relapse - Build on this experience Strategies: Explore triggers + reframe the whole situation as a learning experience + establish a new plan + develop new coping skills

Question 176

What is the question-answer trap in MI?

Answer 176

Too much « expert » questions lead to short answers and seldom opportunity for self-exploring/self-motivational statements OR too much open-ended questions without any reflection (patients don’t feel listened to) --> Strategy: avoid 3 questions in a row, open-ended or not

Question 177

What is the confrontation-denial trap in MI?

Answer 177

While facing ambivalence, dietitian argue for « change » side, which elicits patient to respond with « no-problem » side. Most common trap If you start arguing for change, the client will start arguing for status quo as a protective mechanism --> Strategy: do not argue, rather roll with resistance

Question 178

What is the expert trap in MI?

Answer 178

Enthusiastic dietitian conveys the impression of having all the answers. It inhibits client’s opportunity to explore and resolve ambivalence for themselves (they become passive) --> Strategy: First build intrinsic motivation before giving expert advice (in moderation)

Question 179

What is the labelling trap in MI?

Answer 179

Use of diagnostic labels to identify patients (« You are in denial. ») It may generate stigma in patient’s mind and shows an attempt to assert control and expertise (it sounds judgemental) --> Strategy: Reflect and reframe to respond to questions regarding labels (« It sound like implying you are a binge eater is a worry for you, is it? »)

Question 180

What is the premature focus trap in MI?

Answer 180

Counselor wants to focus on « the real problem » while patient focuses on a broader/different range of concerns. Discord may result. --> Strategy: start early discussion on patient’s concerns rather than those of the counselor

Question 181

What is the blaming trap in MI?

Answer 181

Patient focuses on finding who’s to blame for their behavior. --> Strategy: Blame is irrelevant, reflect and reframe: « It sounds like you are worried about who is to blame. Counseling has a ‘no fault’ policy where we are interested in what is troubling you and what you can do about it. »

Question 182

What is culture?

Answer 182

How people define themselves Definition: The learned or shared knowledge, beliefs, tradition, customs, rules, art, history, folklore and institutions of a group of people used to interpret experiences and to generate social behavior. May include shared behavioural patterns learned and passed on from one generation to the next with respect to: - Beliefs - Food - Traditions - Arts - Rituals - Values - Customs - Communication styles - Practices Shapes how we explain and value the world Becomes an integral part of our life and makes us often unaware of its influence on our thinking, behaviour and attitudes

Question 183

What is race? Name the most common races.

Answer 183

- Group of people with similar skin and facial characteristics. - Based on biological characteristics (skin color, eye color, hair, sizes/shapes). - More common ones: Caucasian/white, Asian (Japanese, Chinese, Korean, Vietnamese…), Black/African-American), native Hawaiian/pacific islander, American-Indian, Alaskan

Question 184

What is ethnicity?

Answer 184

- Shared components of race, language, customs and religion. - Based on cultural characteristics (cultural ancestry, common heritage, common Nations of origin) - E.g. Spanish origin (= Hispanic, Latino) --> might be from Cuba, Mexico, central America…

Question 185

What is diversity?

Answer 185

- Diversity refers to the range of differences among people. - Our identities may be defined by our race, ethnicity, age, gender, sexual orientation, religion, spiritual affiliation, marital status, language, physical or mental abilities, educational background, socio-economic status...

Question 186

What aspects can influence cross-cultural communication?

Answer 186

* Race * Gender * Age * Nationality * Socio-economic status * Religion * Educational background * Sexual orientation * Political affiliation

Question 187

Name a few aspects of communication that differ among different cultural groups

Answer 187

* Body language * Variation in use of expressive language * Degree of directness * Use of eye contact * Amount of personal space needed * Accepted duration of silence

Question 188

What are some issues migrants can go through by coming to Canada?

Answer 188

``` • Culture shock • Downward social mobility • Housing problems • Lack of child care assistance • Language and literacy barriers • Economic limits • Forced immigration • Family members deceased in war or political strife • Uncertain future • Unemployment • Poverty • Gender/Family adjustments (Mother as income source, Child as social liaison) o Father in social decline o Cultural tensions within family ```

Question 189

What can result when socio-cultural differences between patient and provider are not appreciated, explored, understood or communicated in the medical encounter?

Answer 189

patient dissatisfaction, poor adherence, poorer health outcomes and racial/ethnic disparities in care - Prejudice limits our ability to be empathic, genuine, accepting - Without cultural diversity, your intervention could conflict with common beliefs or customs - Some groups remain vulnerable and this has a major impact on the counseling relationship

Question 190

How does culture influence health care?

Answer 190

Culture influences many things: • Experience of health and disease (past) • Beliefs about health and disease (past and present) • Expectations (present) • Behaviours (futures) • Treatment outcomes (future) Therefore, it influences the whole process.

Question 191

Name 2 models used to develop cultural competence

Answer 191

ETHNIC | LEARN

Question 192

Describe the ETHNIC model to develop cultural competence

Answer 192

Explanation - ask pt to explain problem (medical problem) Treatment - ask pt about medicine, home remedies, or other tx considered and expectations from health care team Healers – ask about whether advice has been sought Negotiate - options that may be mutually acceptable Intervention - determine intervention that may be acceptable Collaborate - with the family and community with whom client interacts This model incorporates the client’s explanation and beliefs and guides an intervention to a culturally acceptable plan of action

Question 193

Describe the LEARN model to develop cultural competence

Answer 193

(how to reduce communication barriers with the patient)  Listen- with empathy to the pt explaining the problem  Explain- back to the pt your perception of what was related  Acknowledge – similarities and differences  Recommend – culturally sensitive options  Negotiate – might have to compromise with the pt the plan of action This model helps to reduce communication barriers and entails five steps to guide an intervention

Question 194

What is cultural competence?

Answer 194

“Developing attitudes, skills and levels of awareness enabling the development of culturally appropriate, respectful and relevant interventions”

Question 195

What are some questions to ask about acculturation?

Answer 195

* What languages do you speak? * What language do you think in? * What types of foods do you prefer to eat? * What foods do you usually eat at home? * What are your favorite types of restaurants? * When you select friends, what ethnic background do you prefer? * When you select health professionals, what ethnic background do you prefer?

Question 196

What can be done to start an interview with an interpreter?

Answer 196

- Budget time for set-up, interpretation, and debriefing. - Formally introduce yourself to the interpreter & client. - Always look at client – eye contact with client. - Invite the interpreter to sit next to the client. - Instruct the client to look at the dietitian while the interpreter is speaking (when culturally appropriate). - Insist on direct interpretation. Explain that the interpreter can request a time-out to clarify issues.

Question 197

What can be done during an interview with an interpreter?

Answer 197

- Use short and simple sentences when speaking. - Avoid jargon, acronyms - Ask 1 question at a time. - Speak directly to the client in a normal voice (maintain eye contact when culturally appropriate). - Request a time-out to clarify issues. - Watch for nonverbal communication. - Ensure you are communicating effectively by asking the client to repeat the message back to you. - Interpreter might be a family member – confidentiality issues - Want agreement of the client

Question 198

What can be done during an interview with an interpreter?

Answer 198

- Use short and simple sentences when speaking. - Avoid jargon, acronyms - Ask 1 question at a time. - Speak directly to the client in a normal voice (maintain eye contact when culturally appropriate). - Request a time-out to clarify issues. - Watch for nonverbal communication. - Ensure you are communicating effectively by asking the client to repeat the message back to you. - Interpreter might be a family member – confidentiality issues (want client agreement)

Question 199

What can be done by the counselor when a patient has a mobility impairment or uses a WC?

Answer 199

• Arrange physical environment and eliminate obstacles (remove chair in your office etc.) • Position yourself at eye level • Ask before you help: don’t just push the wheelchair • Some can get out of their wheelchair and walk for short distances and use their arms and hands • Could be someone with artificial limbs • Outdated language - Crippled - Handicapped - Wheelchair bound - Confined to wheelchair • Current language - Wheelchair user - Person who uses a wheelchair - Person with limited mobility

Question 200

What can be done by the counselor when a patient is blind, visually impaired or partially sighted??

Answer 200

* Identify yourself and others with you * Written documentation in very large font * Describe your actions * When walking alongside, note obstacles such as stairs, revolving doors... * Have magnification devices * Offer to read written information * Speech- recognition software, smartphones

Question 201

What can be done by the counselor when a patient is deaf or hard of hearing?

Answer 201

* Sign-language interpreter if available * Speak directly to patient, not interpreter * Face the individual: lip reading * Not all use sign language * Use meaningful gestures and facial expressions * Amplification devices * Speak clearly, rephrase

Question 202

What can be done by the counselor when a patient has speech disabilities?

Answer 202

* Aphesia, stuttering * Quiet environment * Make eye contact * Allow responding time * Speak slowly * Don’t assume it comes with cognitive impairment * Ask questions requiring short answers * Avoid shouting * Speak in an adult manner (avoid talking down) * Use visual aids * Could ask to write down if understanding is challenging * Focus on one message at a time * Active listening, paraphrasing, summarizing

Question 203

What is bias?

Answer 203

“A tendency to favor one explanation, opinion, or understanding over another perspective that is potentially equally valid.”

Question 204

Why do counselors need to be cautious of being biased?

Answer 204

* Counselors’ vulnerability to inferential bias during the counseling process may result in misdiagnosis and improper interventions * Personal biases are a major obstacle in the decision-making process • Identifying our biases will enable us to provide our clients with a non-judgemental environment

Question 205

What are the 3 main types of bias in counseling settings?

Answer 205

1. Cultural, political and religious bias 2. Weight bias 3. Socioeconomic status bias

Question 206

What is weight bias?

Answer 206

- “Beliefs about a persons values, skills, abilities and personality based on their body weight and shape.” - Obesity Canada (2018) says it refers to attitudes and views about obesity and about people with obesity.

Question 207

How can one reduce its own cultural bias as a counselor?

Answer 207

1. Know your patient/client - Race - Ethnicity - Nationality - Heritage - What language barriers may exist? - What cultural context do you bring to the table? - What cultural biases might your client/patient have about you? - What is the cultural context of both your argument and supporting evidence? 2. Cultural competence - Valuing diversity - Identifying areas of prejudice and biases - Adapting to the changing culture of clients/ patients - Use non-verbal as a communication skill with clients/ patients that have limited understanding of English, French or have a disability etc. - Listen and speak effectively

Question 208

What can you do as a counselor to shorten the cultural distance?

Answer 208

- Don’t pass judgment, but build on people’s food and nutrition practices by emphasizing the positive aspects of the food they eat - Try to use educational materials that depict the ethnicity of the clients/patients you are working with - Inquire about your client’s/patient’s beliefs in the role of religion on health outcomes - When possible use visual aids instead of written materials and handouts - Make a strong effort to see the world through other people’s eyes. Recognize that what you think of as a health myth someone else may consider a fact

Question 209

What are common weight biases from dietitians?

Answer 209

Expected not to adhere to recommendations Lacking self-control Unattractive Always overeating

Question 210

Explain the impact of weight bias on health professional's rapport

Answer 210

* Providers demonstrate less emotional rapport with client/patient who are overweight or obese * Client/patient obesity is associated with decreased healthcare provider respect * Healthcare providers are reluctant to perform some health screenings * Decreased expectations of patient & increased aggressiveness toward the client/patient (blame)

Question 211

Explain how weight bias can further obesity

Answer 211

- Obesity leads to some health consequences requiring increased medical visits - Bias in health care leads to negative feelings towards health care and self --> avoidance of health care - Avoiding health care leads to unhealthy behaviours, poor self-care --> obesity

Question 212

What can you do as a counselor to reduce weight bias?

Answer 212

ENVIRONMENTAL o Place the scale in a private area and, when possible, weigh the patient during the visit o Prior to posting anything in the office check the content o Provide wide‐based, higher weight capacity chairs, preferably armless, available in the waiting area and other patient areas o Offer large size or even thigh‐sized blood pressure cuffs o Have extra‐large gowns available SELF-AWARENESS o Educate your staff about obesity and weight bias o Be mindful of the negative experiences the patient with obesity brings with them to the office o Focus on outcomes of health and wellness and less on weight and shape o Explore all the possibilities of causes and understand complexity of obesity o Be aware that the client/patient may have tried several times to lose weight o Recognize that it may be difficult to make lifestyle changes o Set achievable goals COMMUNICATION o Ask permission to talk about body weight o Ask the client/patient what their perspectives of their body weight are rather than assume o Refrain from sharing your own weight loss stories or anecdotal tips

Question 213

What is stigmatizing language about weight and what is preferred?

Answer 213

Stigmatizing - Weight problem - Unhealthy body weight - Unhealthy BMI - Heaviness - Large size - Obesity - Excess fat - Fatness Preferred - Weight - Excess Weight - BMI

Question 214

Name examples of biases in regards to socioeconomic status

Answer 214

* Not educated * Cannot afford healthy foods (i.e. fresh fruits and vegetables) * Often consumes fast food * Lazy and not willing to conform * Substance abusers * Poor communicators

Question 215

How can socioeconomic bias impact counseling?

Answer 215

* Less inclined to work with poor clients and more likely to view them as having more serious disturbances than their wealthier clients * Not showing up for an appointment can be interpreted as resistance to treatment. (May be due to a client's lack of access to child care, transportation obstacles or other factors) * Providing recommendations that may be appropriate for more well-off clients and may not be feasible for others

Question 216

What can you do as a counselor to reduce socioeconomic bias?

Answer 216

* To not make assumptions about those in a lower economic status * Be self-aware when counseling and asking questions * Put yourself in your patient/client’s shoes * Treating all patients/ clients equally * Increase cognitive empathy

Question 217

What are the steps that counselors can take to reduce the likelihood of inferential bias in the counseling process?

Answer 217

1. Attend to the details of sessions that initially seem to be less significant 2. Be aware of the tendency to attribute problems to clients and examine the influence of situational factors 3. Formulate alternative hypotheses 4. Ask what information disconfirms hypotheses. 5. Write down specific reasons for conclusions about clients/ patients 6. Re-evaluate initial impression and diagnosis after several sessions with clients/ patients 7. Wait to review a client’s file or information received from a referral source until after the initial session. 8. Keep accurate, current case notes

Question 218

What are the 5 adult education principles?

Answer 218

1. They bring experience and knowledge (value their experiences, they can share their knowledge) 2. Relevancy-oriented (they like to be convinced that the learning experience will be worth their time and efforts) 3. Autonomous and self-directed (independent, like to be asked for their perspective, want to have a say) 4. Practical (to be motivated, they need to believe the outcome is important) 5. Task centered and problem oriented, life centered 6. Intrinsically motivated (improve quality of life, increase self esteem, health, avoidance of disease..)

Question 219

Name advantages of having a spouse with you at the counseling session.

Answer 219

Both will hear the advice Can check with the spouse for comprehension If spouse does grocery and cooking, allows for questions If client not feeling well, spouse will hear advice Allows you to see interactions between the couple around food choices: allows for coaching

Question 220

Name disadvantages of having a spouse with you at the counseling session.

Answer 220

Spouse may take over Spouse may spend much of the time criticizing the client’s food choices = defensive client that shuts down Spouse may being up his/her own food/diet concerns You might spend your time pulling the client back into the conversation

Question 221

Who needs to set the goal in the counseling relationship?

Answer 221

The client. Our role is to ensure that the goals meet the goal setting criteria

Question 222

Name 4 important goal setting skills/aspects.

Answer 222

* Elicit client’s ideas for change (change talk) * Explore concerns regarding a selected option (probe) * Identify a specific goal from a broadly stated goal (narrow the focus to a specific goal) * State positive goals

Question 223

What is involved in goal setting?

Answer 223

- Giving direction (helps client prioritize) - Defining roles (client knows what is expected) - Motivating (S-E) - Measuring progress

Question 224

Explain the goal setting process

Answer 224

S: Specific, simple, significant M: Measurable, meaningful, manageable A: Attainable, achievable, action-focused R: Rewarding, realistic, relevant, results-oriented T: Timely, time-framed, time-limited

Question 225

Explain what each letter means in terms of what should be determined in the SMART goals

Answer 225

* Specific: identify what, where, when, by whom, with whom * Measurable: identify how much and how often * Attainable: identify if the goal is realistic given the time and available resources * Relevant: identify the importance of your goal to your long term intentions * Time framed: identify the time frame and target date for goal completion

Question 226

At what stage of change can a goal be set?

Answer 226

Preparation.

Question 227

Which term is now prefered to compliance and why?

Answer 227

Adherence is better | Compliance conjures more with an image of an authoritarian counselor dictating “dietary orders” and expecting obedience

Question 228

Name 7 reasons for lack of adherence or "non-compliance"

Answer 228

- Lack of education (need to know what to do) - Faulty health-care beliefs - Lack of necessary skills (knows what but not how) - Lack of adequate support - Constant negative reinforcement - Depression - Forgetfulness

Question 229

What can you do to increase adherence to goal?

Answer 229

Use cues, notes. | Put aside measured amounts. Record intake as consumed. Make plan for each day, check it off.

Question 230

Why is group counseling useful?

Answer 230

Group involvement brings about - better motivation and support for change, ideas. - better implementation of the new practice. The more permanent change brought about in groups is thought to stem from: - A desire to live up to group norms. - A shared perception leading them to call for, and enforce, change themselves. - A public commitment to carry through the behavior decided on by group. - Strong group bonds, which deepen the individual’s new attitude. - Can be more time and cost effective than individual sessions - At times, more effective in the short term than individual session - Some studies demonstrate greater adherence to nutrition recommendations

Question 231

What are the 5 group development stages?

Answer 231

1. Forming 2. Storming 3. Norming 4. Performing 5. Adjourning

Question 232

What is the forming stage of group development?

Answer 232

Stage where group norms are created, just starting to come together – Characterized by anxiety and uncertainty – Members are cautious, driven by wanting to be accepted by others – The goal is for members to become familiar with each other

Question 233

What can you do as a facilitator to make the forming stage of group development better?

Answer 233

– As a facilitator, you have to create an enabling climate, outline the rules of the group, help the group move through orientation, provide guidelines and structure, keep communication open

Question 234

What is the storming stage of group development?

Answer 234

– Conflict and competition are at their greatest – Power struggles emerge – The more dominant group members emerge – The less comfortable members stay in their comfort and security – There is an increased need for clarification, structure, rules.....

Question 235

What can you do as a facilitator to make the storming stage of group development better?

Answer 235

As a facilitator, one of the main challenges is to maintain boundaries, be active, let everyone be heard and express themselves, help the group members focus on what they have in common

Question 236

What is the norming stage of group development?

Answer 236

– The group is becoming a cohesive unit – A sense of community is established – Members are flexible and trust each other – Members are willing to adapt to the needs of the group – Group interactions are easier

Question 237

What can you do as a facilitator to make the norming stage of group development better?

Answer 237

As the facilitator, help the group get back on track as needed, encourage participation, reinforce the positive feel of the group

Question 238

What is the performing stage of group development?

Answer 238

– Not every group reaches this level – There is a sense of group unity – High productivity – Group members are supportive – Problem solving and fulfilling the goals is high

Question 239

What is the adjourning stage of group development?

Answer 239

– This is the closure stage of a group – Many members don’t know how to deal with endings, goodbyes – Some members might be angry instead of being sad

Question 240

What can you do as a facilitator to make the adjourning stage of group development better?

Answer 240

As the facilitator, you have to validate their feelings, do a group closure activity, honor what was accomplished as a group

Question 241

Name advantages of group counseling

Answer 241

- Emotional support (not alone) - Group problem solving - Modeling effect (good influence --> hope) - Attitudinal and belief examples (helps other participants reevaluate their belief systems) - Can help more people with your time - Powerful social support process for group members - Shown to be more effective than individual counseling - You may find it more fun - Can support a person’s hope for real change by seeing others make changes

Question 242

Name disadvantages of group counseling

Answer 242

* Variable individual responsiveness. * Difficult personalities of some. (leader has to handle dominating, demoralizing or needy clients) * Individual personalities heavily influence dynamics. * Ability of leader to handle those who monopolize time impacts the counseling environment for all. * Some do not easily share in a group - their issues may never be addressed. (group leader’s responsibility to encourage participation of all members of the groups without putting someone on the spot, or blaming as it has a negative impact on group dynamics) * Possibility of poor role models - can create additional burdens for a counselor to counteract. * Difficulty of meeting needs of all group members. * May be difficult to organize a group with similar issues and health concerns. * Meeting the needs of widely different ages, genders, and ethnicities can be a challenge. * Negative energy from one person may bring down the whole group * More preparation time required

Question 243

Name important things to do/considerations for group counseling

Answer 243

Allow adequate time for organization: 6-8 wks to arrange meeting location, publicize, develop curriculum. Ideal group size for a closed group is 8-12. Too large - poor flow of conversation; difficult to give individual attention. Too small - dynamics of the group too severely affected if one or two are absent. Select a comfortable meeting room, location. • Sitting around table or U shape or round table • Avoid rectangular tables (reduce exchanges) • Space to break into smaller groups • Easily accessible by public transportation • Large patients = sturdy chairs Encourage listening (phones off) Appraise group before setting the meeting time Interview prospective group members (phone?) Consider composition of the group - similar goals/needs (If composition is mixed, numbers should be balanced, so no one feels left out.) Group leaders should remain the same Consider collecting fees or refundable deposits (better attendance) Be responsible (start/finish on time, prepared etc.) Consider refreshments - sharing food encourages bonding Call members who miss meetings Do something to give the group prestige (membership cards, pins, certificates etc.) Ask for group's concern and track them Discuss and decide on "rules of interaction" (ranse hand?) Consider having a separate group for spouses, supporters Use rewards ? Obtain written evaluations from members at the end Do not take sides when listening to group members Use name tags at the beginning and learn participants names quickly

Question 244

Name 7 guidelines for effective group facilitation

Answer 244

1. focus on feelings (to get support from group) 2. Be an active listener (don't interrupt or allow others to do so) 3. Clarify, use familiar words 4. Be respectful 5. Correct misinformation 6. Summarize 7. Provide resources

Question 245

How should latecomers be dealt with in group counseling?

Answer 245

Be sure that you start and end on time to convey the right message.

Question 246

How should aggressive behaviour be dealt with in group counseling?

Answer 246

Reflect and redirect. Refocus the group on the topic of discussion

Question 247

How should blocking behaviour be dealt with in group counseling?

Answer 247

If behavior does not change, arrange to meet privately with the group member

Question 248

How should dominating behaviour be dealt with in group counseling?

Answer 248

Acknowledge that they seem to know a lot. Ask about their sources of information. If sources are questionable, ask others in the group what they believe.

Question 249

How should withdrawing behaviour be dealt with in group counseling?

Answer 249

“We would really like to hear from you today. Would you share your feelings about this?”

Question 250

How should wisecrackers be dealt with in group counseling?

Answer 250

Some degree of humor may be helpful in the group. When you determine that the humor stops being helpful and creates tensions and starts interfering with group learning: Ex: “I appreciate what you are saying, but time to get back to the issue”

Question 251

How should silent people be dealt with in group counseling?

Answer 251

* Use eye contact to encourage participation * Try to figure out the reason explaining the quiet member * Could use an icebreaker activity

Question 252

How should complainers be dealt with in group counseling?

Answer 252

Acknowledge them and ask for their suggestions and be firm about staying on track

Question 253

How should side conversations be dealt with in group counseling?

Answer 253

Pause until conversation stops Stroll over and stand next to the talkative participants Ask: “do we need to take a break?”

Question 254

How should inarticulate statements be dealt with in group counseling?

Answer 254

Say:“Thank you-let me repeat that” Then put ideas in a better language”.

Question 255

How should participants statements that are definitely wrong be dealt with in group counseling?

Answer 255

Say: "That's great that it worked for you, but others have found..." or “I see your point, but let’s try looking at it this way”

Question 256

How should people who are seeking for leader's opinion be dealt with in group counseling?

Answer 256

* Avoid solving problems * At times, you should give a direct answer * Could open up the discussion to other participants

Question 257

How should the counselor end a group session?

Answer 257

• Bring closure to the group Ending • Summarize the high points of the meetings • “What was it like to be part of this group”? • “What do you think has benefited you the most”? • “How helpful was the group process for clarifying your desired behavior change or for making your desired behavior change”?

Question 258

What are the 8 main responsibilities of group facilitators?

Answer 258

1. Be accessible 2. Be a good active listener 3. Be respectful and empathetic 4. Be a quick thinker 5. Be assertive 6. Use humor 7. Energize the group 8. Keep the process on track, participants engaged, to make the best of the time.

Question 259

What is confrontation?

Answer 259

One of the basic counseling responses • Is about nothing a discrepancy and challenging it • Confrontation is not a hammer: it’s a gentle push

Question 260

How should confrontation be done?

Answer 260

Interviewer tactfully and tentatively calls to the person’s attention some inconsistencies in a person’s story or words and actions, pointing out the discrepancies. Offering constructive, growth directed feedback that is positive in context and intent, not disapproving or critical. It is seeking clarifications which might permit creative resolution of difficulties.

Question 261

What to confront?

Answer 261

* How someone feels (ex: their anxiety) * How someone thinks (ex: accuracy of their knowledge) * How someone behaves (ex: missed appointment) * Lying (to present false information)

Question 262

What does effective confrontation involve?

Answer 262

1. Assessing the purpose of confrontation 2. Avoid at the beginning phase of counseling 3. Use skillful questioning 4. Prior to confronting, build rapport and trust 5. Do not overload with confrontations; only one at the time 6. The end of a counseling interview is generally a poor time to confront

Question 263

What are the steps involved in confrontation?

Answer 263

STEP 1: - Understand the issue and the client's message - Wait until you have heard the client's whole story - Ask yourself is the timing right? STEP 2: - Present the challenge in a way the client will most likely accept it - You can use the approach: “On one hand _______; on the other hand________” STEP 3: - Observe the client's response to the confrontation (denies? partially/fully accept?) STEP 4: - Follow up the confrontation by rephrasing - If the client does not accept the confrontation or denies, the counselor should be ready to follow up with additional exploration

Question 264

What can you do to confront someone who has differing verbal and non-verbal cues?

Answer 264

“ you said that you were happy but I don’t see it in your face”

Question 265

What can you do to confront someone who has differing verbal cues and actions?

Answer 265

“ you said you were excited about losing weight but you haven’t been coming to your appointments”

Question 266

What can you do to confront someone who has verbally said two differing statements?

Answer 266

“ sometimes you say that you are happy with your job but other times you threaten to quit”

Question 267

What is the best way to confront?

Answer 267

Counsellor focuses on the strengths and what the client can do that will be more effective- people are motivated more by positive feedback then negative one “ I think your best work as happened on those days when you came on time and when you took the effort to focus. My sense is that if you could make every appointment you’d get a lot more out of our time together”

Question 268

When should a counseling relationship be terminated?

Answer 268

Ideally, counseling ends when our client has successfully worked through the various foals, taken action and maintained changes or when client is no longer benefiting from counseling - Counseling goals obtained - Client has developed a sufficient capacity to work on their own - Sometimes it ends because client required referral (ex: psychotherapy) - Client is not following the plan - Client not paying the counseling fees - Insurance coverage imposes a time or cost limit - May be an abrupt end (ex: moving away, illness) - May fade through missed appointments or infrequent attendance - Counselor moves to another area of work

Question 269

What should be done at a client's final session?

Answer 269

Review beginnings ◦ discuss issues that brought client to you ◦ review initial assessments Discuss progress ◦ identify goals, decisions made and progress in meeting them (have your notes) Emphasize success ◦ review accomplishments ◦ credit client for successes Summarize current status ◦ highlight: coping skills, social support, current biochemical parameters, environmental issues..... Explore the future ◦ how will the changes be maintained? ◦ what new challenges will be encountered? ◦ how will difficulties be handled? ◦ any additional changes to be made? ◦ discuss possibility of follow-up meetings (phone, e-mail...) ``` Final goodbye ◦ acknowledge the end ◦ shake hands ◦ walk to the door with client ◦ positive reinforcement ◦ client might express appreciation ```

Question 270

Name 6 potential barriers to optimal nutrition and mental health

Answer 270

1. Food insecurity Unstable income, inability to procure food, poor access 2. Social isolation Stigma, social anxiety, depression, PTSD 3. Medication side-effects Weight gain, glucose de-regulation, dry mouth, altered taste 4. Substance use Caffeine abuse, alcohol abuse, related deficiencies 5. Symptoms of mental illnesses Food disturbance, hallucination, ↓ motivation 6. Metabolic co-morbidities Metabolic syndrome – HTN, Diabetes, Dyslipidemia, Obesity

Question 271

What are the nutrition implications of anxiety/overactivity?

Answer 271

Mindless eating, ↑ energy output Intervention: Reduce caffeine, small frequent meals

Question 272

What are the nutrition implications of Avoidance/Social isolation?

Answer 272

Isolation may induce overeating/undereating Not shopping for food, avoid meal times Intervention: Nutrition therapy as a support to encourage what the client is able to do

Question 273

What are the nutrition implications of depression?

Answer 273

Lack motivation, low energy levels, Severe lack of appetite, poor hygiene practices, prefers foods that require less preparation, over/undereating Intervention: -Encourage a well-balanced diet, one small step at a time -Encourage socialization at mealtimes

Question 274

What are the nutrition implications of insomnia?

Answer 274

- Can alter intake (usually increased) - Can lead to night eating syndrome and ↑wt -Fatigue may lead to ↑↑ caffeine intake and dehydration Intervention: -Suggest lower-calorie and healthy options if night eating is an issue - Avoid caffeine eight hours before sleep - Help incorporate more balanced food and eating habits during the day

Question 275

What are the nutrition implications of weight gain?

Answer 275

-Common in depression, bipolar, and psychotic disorders (e.g. schizophrenia) -Related to the condition or medications Intervention: -Increase fibre intake to enhance satiety -Relaxation (mindfulness) techniques to help slow down during meals

Question 276

What are the nutrition implications of mania?

Answer 276

-High distractibility may lead to poor intake -Irritable mood, hyperactivity Intervention: -Encourage balanced and small, frequent meals