Jason Park

TR5207 Section B
2/25/2014
Counseling Assignment #2
List of prepared questions for each stage (identified according to stage), whether all used or
not:

Stage I Questions
o The purpose of todays visit is to explore and set goals to achieve solutions to
problems
o Todays agenda will include looking at your 24 hour diet recall analysis and
exploring any goals or questions you may have about that, how does that sound
to you?
o Have your dietary patterns changed since we last met?
o Has your weight changed since we last met? If so, what was the time span of the
gain/loss of weight?
o Has your appetite changed since we last met?
o Has there been anything in your life that has may have changed your eating
pattern?

Stage II Questons
o What did you want to talk about today?
o What is it about this problem that makes you want to change?
o What troubles you about the problem?
o What does it mean to you?
o How would your life be different after this change?
o Does this problem effect you physically, emotionally, or socially?
o As promised, I analyzed your 24 hour diet recall, would you like to review the
analysis together?
o So I noticed a few things I am concerned about, is it alright if I share them with
you? How do you feel about the things I am concerned about?
o On a scale of 0 to 10, 0 meaning not very important and 10 meaning very
important, how important is it for you to make this change?

Jason Park
TR5207 Section B
2/25/2014
o Why a (clients chosen number) and not a (number less than clients number)?
o Have you thought of any short or long-term goals you would like to achieve?

Stage III Questions

o Why dont we explore some possible solutions for the problems together, how
does that sound to you?
o Can you give me an example of when you were succesfull in making a change in
the past?
o Can you give me an example of when you werent succesfull in making a change
and what you learned from it?

Stage IV Questions
o Now that weve identified some solutions, why dont we try to make a few small
goals. How does that sound to you?
o What are some barriers that you think would prevent you from reaching your
goal?
o What are some things we could do to anticipate or cope with those barriers?
o So it seems like we came up with a good plan to achieve your goals, what do you
think or how do you feel about that?

Stage V Questions
o If it is alright with you, I can share a few things I know about this issue.
o Some people respond positively to signing a contract to hold them accountable
for their change, what do you think about possibly doing something like that?

Stage VI Questions
o In summary, these are the changes that we will be working on, does that sound
about right to you?
o How do you feel how the session went, do you feel confident moving forward?
o What are you plans for the upcoming week to achieve your goals?

Jason Park
TR5207 Section B
2/25/2014
Brief re-introduction of client and main issue(s) identified to work on:
Jane Doe comes back in today for a follow up visit for possible weight loss solutions.
Jane is a student in an acupuncture and oriental medicine program. Jane is in her mid to late
40s with a BMI on the border of overweight. Jane has not been feeling well since we last met.
Her appetite has decreased and subsequently has had weight loss because of her condition.
Since Janes current condition and appetite has been effected, we agreed that weight loss may
not be the best problem to work on at todays session. I also did not feel comfortable
addressing her weight loss issue because she had estimated to have unintentionally lost 6 lbs
since we last met due to the decreased appetite and diarrhea. Jane mentioned she was
currenty seeing a chinese herbal medicine doctor for her current condition and that she is
opposed to traditional western medicine. We reviewed the 24 hour diet recall analysis and
identified a few concerns. One concern she identified was her calcium intake, which was 58% of
the RDA. She identified it as an 8 out of 10 on how important it was for her to change. Jane said
she would be concerned about her long-term health and specifically her bone health. Jane was
also concerned about her fat intake at the first session, however upon review of the diet
analysis Jane rated the importance of changing her fat intake as a 5 out of 10.

Current state of readiness to change; any scaling that was used & how received by client
Potential solutions that were brainstormed
Jane seemed very motivated to increase her calcium intake to support her health, she
rated her confidence in changing her calcium intake a 10 out of 10. Since Jane views food as
healing, I asked her what she thought about increasing calcim intake through foods, as I
remembered from the previous session that Jane views food as medicine. That idea seemed to
resonate with Jane and I observed her body language change positivitely. I noticed Jane did not
have any dairy intake and learned that Jane has a dairy sensitivity, which ruled out calcium from
dairy sources. I then asked Jane if it was alright if I shared a few plant sources that are high in
calcium, to which she agreed. I shared that dark leafy greens such as spinach, kale and collard
greens have a good source of calcium intake. Jane became very excited and said that she loved

Jason Park
TR5207 Section B
2/25/2014
spinach and so we thought of ways we could incoporate more spinach into her diet. Since Jane
hasn not been feeling well, she has been eating more soups and broths. I asked Jane on a scale
of 1-10, how interested was she in incoporating spinach into her soups or broths and she rated
her interest as a 9 out of 10. I asked Jane about possibly incoprorating kale or collard greens
into her diet, and she said she did not know how to prepare these foods. Jane then said she
noticed some recipes on the Bastyr website and said that she could probably look them up. I
said that was a great idea and that she could even look up other ways to prepare these foods
on the internet. I identified Jane as being in the prepatory phase, where she is ready and
confident in making changes to her calcium intake.
Another concern I had was Janes fat intake, as she was consuming about 24% above the
recommended intake. As we were going through the diet analysis I expressed my concerns and
asked Jane how she felt about it. Jane became a bit defensive, saying it is only above 24
percent. I asked Jane how important it was to change her fat intake, which she rated a 5 out of
10. I asked Jane why a 5 and not a 2, and she said that she is open to the idea of possibly
changing her fat intake, but she did not think it was that important. I could sense that Jane was
not happy about even talking about fat intake and seemed like she was in the precontemplative
phase.

SMART goals created & strategies developed to overcome barriers; educational materials
used
I asked Jane if we could try an experiment with a few goals to increase her calcium
intake. I then proceeded to ask Jane how confident she felt about incorporating spinach into
her soups once a week, and she rated it a 9 out of 10. Jane seemed very confident because she
enjoys spinach and said it would be easy to incoporate it into her meals. I then asked Jane how
she felt about researching ways to prepare kale and collard greens and she rated her
confidence an 8 out of 10. So we set a goal together to incoporate spinach into her meals at
least once a week, and also by next visit she will have researched different ways to prepare kale
and collard greens. Jane identified that the largest barrier for her was time. One of the ways she

Jason Park
TR5207 Section B
2/25/2014
said she thinks she can be succesfull is by preparing meals ahead of time so that when she is
busy, healther foods will be easier to access.
Behavioral contract (if client refuses or if inappropriate, then discuss your experience)
I chose not to use a behavioral contract because I did not feel like I had built enough
rapport or gathered enough information to gauge how Jane would respond to it. I also felt
unprepared in the scenario of Jane reacting negatively towards the contract.

Brief discussion (<3 pages) of what worked and what didnt what you would do differently,
incorporating terms & concepts learned in class and from textbooks.
After reviewing the recording of my counseling session with Jane, I found a few areas of
improvement and also things I might have done differently. One of the largest challenges I
faced was the client coming in with a completely different issue than what we had briefly
discussed in the first session. We had previously discussed weight loss as a potential area to
work on last session and I had prepared the second session around the weight loss goal.
However, Jane came into the session feeling ill because she thinks she has been having issues
with her adrenal glands. Jane said she had lost 6-7 pounds since the last time we met and has
had diarrhea. She had also lost her appetite and was not eating much lately, which lead to
decreased energy levels. As I explored these issues with her I tried searching for potential
solutions such as increasing her appetite in hopes that it might help her eat more and give her
more energy. But Jane made it clear that she felt full from eating small meals and also because
of her diarrhea, she felt like it was not a good idea to eat more. Overall, I felt uncomfortable
addressing this issue and it showed during my session, as I felt I kept paraphrasing issues
repeatedly because I had lost a sense of direction. I have learned that clients will have different
issues come up and I need to be more mentally prepared to tackle new issues instead of being
uncomfortable.
Another important area I should have explored with Jane is her ambivalence to changing
her fat intake. In the first session Jane mentioned she was interested in how she could maintain
her weight with her current fat intake. But in the second session when we reviewed her fat

Jason Park
TR5207 Section B
2/25/2014
intake, she became defensive about addressing that issue. She stated she did not want to
reduce that and started talking about how she was consuming fats primarily from plant
sources and she thought her fat intake did not need changing. I started to feel uncomfortable
about addressing this issue and almost felt like I may have been trying to make it an issue, when
the client felt like it was not. In hindsight, I should have asked her more open questions about
why she was not concerned about her fat intake. I also could have, with her permission,
provided information about the Acceptable Macronutrient Distribution Range (AMDR), which
would explain to her why her current fat intake may not be supporting her health.
Once we reviewed the 24 hour dietary recall analysis, we were able to target calcium
intake as a possible change Jane could make into a SMART goal. I suggested that Jane could
incoprorate spinach into her meals once a week. In retrospect, I do not think this was specific
enough and did not fit the SMART goal format. I should have recommended that she try to
incorporate spinach into her lunch 3 times a week, which would have better fit the SMART goal
format. Similarly, we made another goal to research ways to prepare kale or collard greens by
the next session, but I do not think this fit the SMART goal format either. Instead, I should have
suggested that Jane research 2-3 methods to prepare kale or collard greens before the next
session.
Another area I felt I could improve on is buillding self-efficacy with the client. I think in
retrospect I could have utilized the behavioral contract which might have helped Jane feel more
confident and responsible to reach her goals. I did not choose to use the contract because I felt
uncomfortable about responding to how Jane may react to it. Instead I could have shown the
contract to her and asked her how she felt about creating a contract and if she thinks it might
help her reach her goals. In the scenario of Jane not liking the idea, I could just respond by
saying that it that it is alright if she does not want to do it and it is something I suggested
because it has worked for other clients.
Overall, I think the largest challenge was being able to adapt to any new issues that
might come up with a client. I felt like I was out of my elemnt during the sesson because I had
prepared for weight loss as the issue, since that what we had talked about in the first session. It

Jason Park
TR5207 Section B
2/25/2014
make me appreciate that in reality, clients will have dyamic issues and have life changing events
that might make current issues a lower priority compared to the new issues.

Nutrition Counseling Assessment Checklist TR 4207/5207

Session

II

While viewing or listening to the recorded session of the counseling encounter; comment on the
following areas.
Keep track of how many open-ended and closed-ended questions you notice throughout the
session.
Nutrition Counseling Session

Yes

Examples from Session/Comments &

Alternatives

So it seems like you just havent been

feeling well in the past few weeks.
So it seems like you feel that you are
consuming the right foods, but the results
arent reflecting that.
So it seems like the main issues youve
been having lately is getting more energy,
decreased appetite and not being able to
eat much. What else have youve done to
increase your appetite?
It seems like you get very excited when
you talk about eating coconut products, it
seems like its something you really enjoy.
Today we are going to explore the issues
we talked about in the last session and
explore possible goals for those issue this
session. How does that sound to you?

1. Open the Session & Build a

Foundation
a. Simple listening

b. Reflection of words

c. Paraphrasing for in-depth exploration

d. Reflection of feeling

e. Negotiate the agenda & provide

feedback

2. ID Problems & Elicit Change Talk: I

want, I can, I need

a. Ask key questions

b. Discuss barriers to change

c. Discuss values, relationships,

meanings of food

Why is this change important for you? How

would your life be different with this
change?
So what are the barriers you feel might
hinder your efforts to reach your goal?
We talked about in the last session that red
meat isnt something that you are
particularly drawn to, so Im wondering
whats changed to make you trying to
incorporate more of it into your diet?

Jason Park
TR5207 Section B
2/25/2014

On a scale of 1-10, 1 being not very

(important, confident, interested) and 10
being very (important, confident,
interested), how (important, confident,
interested) is this change for you?

So on one hand it seems like you would

like to eat more to support your health, but
on the other hand because you are not
feeling well, eating more would not make
you feel better.

d. Assess importance, confidence, &

readiness to change

e. Explore ambivalence
f. Use decisional balance (benefit vs.
cost; pro vs. con)

g. Use extremes related to the problem

(e.g., client worries)

I noticed you got excited when we talked

about incorporating spinach into your diet,
it seems like it is something you enjoy
eating?

h. Focus on past; focus on future

i. Explore goals/values; begin to set

goals

3. Brainstorm Possible Solutions

So the short-term goal could be increasing

your calcium intake, and the long-term
health goal would be to support your bone
health.
Since youve looked up recipes for kale,
perhaps you could research how to
prepare collard greens as well.
Youve been making soups to help your
feel better, perhaps you could add in some
spinach, kale or collard greens to your
soup.

4. Set Goals & Develop Coping

Strategies

a. SMART goals (specific,

measureable, attainable, realistic,
and timely)

b. Goals involve client behavior & are

under clients control, i.e., do not
require actions of someone else

Did you want to try an experiment? We

could try incorporating kale, spinach, or
collard greens into your meals once a
week.
Client is to research methods to prepare
kale or collard greens and incorporate
spinach into her meals.

So it seems time is a barrier for your with

your busy schedule.

You mentioned earlier that youve tried to

c. Identify barriers to goals (lack of

client knowledge, skills, ability to
change or social support)

Jason Park
TR5207 Section B
2/25/2014
d. Plan strategies to overcome barriers

e. Set time limits for specific change

activities

f.

Encourage and support change;

empowerment

pre-prepare meals ahead of time, maybe

you could try that again so we can
overcome the time barrier.
So by our next session, you will have
incorporated spinach into your meals once
a week, and also have researched ways to
prepare kale and collard greens.
You seem very excited and confident
about incorporating spinach into your
meals. Spinach is something you enjoy
and seems like it will be an easy task to
incorporate into your meals. Does that
sound right to you?

5. Provide Advice & Information and

Commit to Change

a. Provide or revisit nutrition education

b. Ask permission to give advice

If its all right with you, I can share the

calorie content of fats vs carbs and protein.
Fat has 9 kcal/g vs carbs and protein
which have 4 kcal/g.
If its all right with you, I can share the
calorie content of fats vs carbs and protein.
Fat has 9 kcal/g vs carbs and protein
which have 4 kcal/g.

c. Build feelings of self-efficacy

d. Create & sign nutrition and/or
behavioral contract
6. Summarize & Close the Session

You seem excited and ready for this new

change.

Our next session will be in a few weeks

and I will send you an e-mail so we can set
up a specific date and time.

I understand you have a busy schedule, so

I appreciate your time and commitment to
our session.

a. Support empowerment, self-efficacy,

affirmation
b. Encourage independence, but
reinforce plans for relapse
c. Arrange follow-up appointment (or
terminate sessions)
d Link with available resources
e. Thank client/show appreciation

Avoid getting caught in the following

Jason Park
TR5207 Section B
2/25/2014
traps:
Question-answer trap
Taking sides trap
Expert trap
Closed vs. Open ended Questions (count
the number of closed and open-ended
questions)

12 open and 14 closed questions

Premature focus trap

Blaming trap

What other Basic Counseling Responses

did you notice?
Advice
Allowing Silence
Attending (Listening)
Direction (Instructions)
Noting a Discrepancy (Confrontation,
Challenging)
Eye contact
Legitimization (Affirmation/Normalization)
Mirroring, Paraphrasing, and/or Giving
Feedback

Allowed for silence after client paused,

which elicited additional responses

Maintained appropriate eye contact

I noticed client became excited when

talking about coconut butter, so I
responded by saying, You seem very
happy when you talk about coconut
foods, can you tell me more about that?

Personal Support
Questioning, Clarifying

Reflection (Empathizing)

Client had stated disinterest in meat in

previous question, however she said
she was trying to incorporate more meat
into her current diet. Clarified this with
the client.
Client is a student as well, so I could
empathize with her about lack of time
and busy schedule

Respect
Self-Referent
a. Self disclosing-about oneself/coping
b. Self-involving-feelings and emotions

Jason Park
TR5207 Section B
2/25/2014

Nutritional Counseling Client Feedback Form

1. What one thing stood out for you from this session? What might you remember and take home with
you?

The fact that my dietry calcium intake is so low. I will be focusing on getting the dark
green leafy vegetables back into my diet.
2. Did the counselor listen to you? Did you feel heard? Rate this on a 7-point scale with 7 representing
that you felt very much listened to and 1 that you were not heard.

Low
1

Medium
4
5

High
7

3. What, if anything, did the counselor miss that you would have liked to explore today or in a future
session, if possible? What else might you have liked to share?
We covered everything

4. What did you find most helpful? What did the counselor do that was right? Please be specific. For
example, not You did great, but rather, When I talked about _______, you listened to me very
carefully.

I liked the way you encouraged me to think about reducing coconut milk in my tea.
5. Overall, rate the quality of this session in terms of its helpfulness.

Low
1

Medium
4
5

High
7

*Please share any other comments or suggestions below: