dietary targets and may involve other healthcare professionals.

Conclusion

Dietary modification underpins many aspects of dietetic practice and it is vital that
the dietitian understands the principles detailed in this chapter so that these
principles can then be applied to practice.

References
American Dietetic Association. (2002) Position of the American Die tetic Association total diet
approach to communicating food and nutrition information. Journal of the American Dietetic Associa-
tion 102: 100–108.

British Dietetic Association (BDA). (2012) Nutrition and dietetic care process. Available at
http://members.bda.uk.com/profdev/ profpractice/modeldieteticpractice/index.html. Accessed 2
Decem ber 2012.

Bronner Y. (1994) Cultural sensitivity and nutrition counselling. Topics in Clinical Nutrition 9: 13–
19.

Department of Health. (2001) The expert patient: a new approach to chronic disease management for
the 21st century. Available at www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/
@en/documents/digitalasset/dh_4018578.pdf. Accessed 2 Febru ary 2012.

Fine J. (2006) An integrated approach to nutrition counselling. Topics in Clinical Nutrition 21: 199–
211.

Gable J. (1997) Counselling Skills for Dietitians. Oxford: Blackwell Scientific Publications.

Hunt P, Pearson D. (2001) Motivating change. Nursing Standard 16: 45–52.

National Patient Safety Agency (NPSA) Dysphagia Expert Reference Group. (April 2011) Dysphagia
Diet Food Texture Descriptors. Available at www.bda.uk.com/publications/statements/National
DescriptorsTextureModificationAdults.pdf. Accessed 2 February 2012.

Prochaska J, DiClemente C. (1986) Towards a comprehensive model of change. In: Miller W, Heather
N (eds) Treating Addictive Behav- iours: Processes of Change. New York: Plenum.

Thomas J. (1994) New approaches to achieving dietary change. Current Opinion in Lipidology 5: 36–
41.

Thomas J. (2002) Nutrition intervention in minority ethnic groups. Proceedings of the Nutrition
Society 61: 559–567.

SECTION 1
1.3
Dympna Pearson

Changing health behaviour

Key points

.   The art of dietetic practice is to integrate the science of food and medicine with
the psychosocial aspects of people’s lives in the context of changing health related
behaviours.

.   An integrated approach to changing health related behaviours embraces the

underlying theory, principles, skills and processes that are necessary to initiate and maintain
changes to lifestyle behaviours.

.   A behavioural approach is directive and client centred. Consultations need to be

structured and focused, where both the practitioner’s and service user’s (client’s) agendas are
considered through working in a collaborative way.

.   There should be clarity of purpose and it must be ensured that any goals agreed
will help the client achieve the desired outcome.

.   Increasing self awareness is an important aspect of becoming an effective change

agent, as is working collaboratively with clients.

‘I do not understand my own actions. For I do not do what I want, but I do the
very thing I hate.’

(Romans 7:15 Revised Standard Version)

Dietetics was originally based on the traditional medical model of expert led,
advice giving with the expectation that once people are told what to do, they will
follow this advice. However, research has shown that giving advice alone does not
automatically change behaviour (Thomas, 1994; Contento et al., 1995; Thorogood
et al., 2002). The challenge for dietitians and other healthcare profession- als is to
develop an understanding of what influences health behaviour and to acquire the
necessary skills that will enable them to facilitate change.

Traditional medical care has moved towards a client centred model that takes into
account the psychosocial aspects of care, as well as the clinical picture (Stewart,
1995). Setting the stage psychologically is of prime impor- tance when helping
others change their behaviour (Brownell & Cohen 1995a; 1995b). It is necessary
to have some understanding of a person’s previous experience and how they think
and feel about their situation, as this will ultimately influence their health
behaviour. Attitudes, beliefs, individual learning styles and the social, cultural,
religious and economic situation will also affect their behaviour.

The environment in which somebody lives has a major influence on health. Public
health interventions, such as those proposed in Healthy Lives, Healthy People
(Depart- ment of Health, 2011), are designed to make healthy choices easier and
are likely to have maximum impact if fully implemented. If people are motivated
to change

their health behaviour, easy availability of healthy and economic choices will
support the process. Dietitians have a key role to play in implementing food health
poli- cies, which are of major importance if better health out- comes are to be
secured in the future. This chapter focuses on achieving change at an individual
level and how interventions can be maximised through enhancing traditional
practice to achieve an integrated approach to changing health behaviours.

An integrated approach to changing health behaviour

A range of approaches can be used to facilitate health behaviour change. Different

approaches may work for different people at different times. An integrated
approach to changing health behaviour in dietetic practice:

• Enables the client to take the next concrete, practical step to change eating or
other lifestyle behaviours.• Combines a directive and non-directive client centred

approach by using a guiding style (Rollnick et al.,

2010).• Includes a range of tools and approaches adapted

from the world of psychology to provide information, strengthen motivation and

facilitate behaviour change, taking the client’s context into consideration.

• Integrates whichever approach seems most relevant for that individual at any
given time, e.g. exploring motivational difficulties or working on modifying
behaviour.
Manual of Dietetic Practice, Fifth Edition. Edited by Joan Gandy.© 2014 The British Dietetic
Association. Published 2014 by John Wiley & Sons, Ltd. Companion Website:
www.manualofdieteticpractice.com

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26

Box 1.3.1 Models used to influence health behaviour

The Helping Model (Egan, 1998)A simple three stage model for use within a
consultation which helps guide the dietitian through the interview in a structured
way:

• Stage 1 (the assessment) establishes the current scenario and helps both client
and practitioner work towards a common agenda as a basis for moving to
Stage 2

• Stage 2 involves exploring the options, setting goals and developing a change
plan

• Stage 3 is the action stage, which mainly happens outside the consultation, with
the sessions used for monitoring, review and follow-up The
Transtheoretical Model (Stages of Change Model) (Prochaska &
DiClemente, 1986).The model can increase understanding of the process
people go through to make changes; people who successfully change go
through:

• A thought process (weighing up the pros and cons of change) and

• A preparation stage before embarking on

• An action stage of change. Most people who reach a stage of maintaining

change have gone through the process of thinking, preparing, action and
relapse several times before eventually changing permanently. This
highlights the ongoing nature of change and that many different
interventions may be required depending on the stage a person has reached.
The limitation of this model are that, because of the shifting nature of
change, it is not possible to identify someone as being in a particular stage.
In addition, people may be at different stages for different eating
behaviours.

Section 1: Dietetic practice

• Treats the whole person, taking into account the world in which they live, what
matters to them and the factors that are likely to influence their health
behaviour. It looks at how diet and activity fit into the client’s life.

• Recognises that the skills and mindset of the practi- tioner will influence how
effective they are as a behav- iour change agent. It therefore acknowledges
that the need for practitioners to engage in ongoing self devel- opment and
self awareness as part of continuing pro- fessional development is just as
important as it is for them to facilitate this process in their clients.
Differences between traditional advice giving and an integrated
approach to changing health behaviour The traditional approach often
consists of advice giving combined with persuading the client to adopt a
preferred course of action. This approach can render the client a passive
recipient of expert knowledge, and can reduce client autonomy and create
discord in the helping rela- tionship (Heritage & Sefi, 1992). When the
client’s per- spective is not fully taken into account, it is possible that
mental and/or emotional harm may be inflicted, which can have long
lasting consequences. In an integrated approach to changing health
behaviour, first do no harm is as applicable as in any other clinical
procedure. This means that practitioners need to be mindful of the client’s
overall situation rather than just following their own agenda (see Chapter
1.1). A consultation based on an integrated approach to changing health
behaviour has the following characteristics:

• The client and practitioner work together as equal partners.

• The client is treated with courtesy and respect at all times.

• Information and ideas are shared.

• The language and approach is collaborative.

• The client is actively involved and there is a two way conversation.

• The practitioner actively listens and interprets what the client says, checking for
understanding.

• There is common agreement and a clear plan about the way forward.
Foundations underpinning behaviour change approaches The
foundations of an integrated approach to changing health related behaviours
are its theoretical underpin- ning, guiding principles, good communication
skills and ongoing practitioner development. Theoretical underpinning
Models A model attempts to understand and describe what factors affect
behaviour and from this, specific approaches and
applications are developed to effect or influence this behaviour. There are a
number of health behaviour models that contribute to the understanding of human
behaviour in relation to health. The models that have had most influence on
dietetic clinical practice are the Helping Model (Egan, 1998) and the
Transtheoretical Model of Change (Prochaska & DiClemente, 1986) (Box 1.3.1).
The complexity of human behaviour can never be fully understood; therefore, no
model or approach can be complete or definitive. Models can however help under-
standing of how things function. An integrated approach to changing health related
behaviours embraces elements from many different models and approaches.

Psychological approaches

The most commonly used psychological approaches in dietetic practice are

motivational interviewing (MI), behaviour therapy (BT) and cognitive behaviour
therapy (CBT).

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1.3 Changing health behaviour

27

Motivational interviewing

Motivational difficulties are often the greatest challenge for people struggling with
change. The task of the dieti- tian is to tap into the intrinsic motivation that exists
within each individual and to help build and strengthen that motivation in order to
facilitate change. Clients often express a desire to change but somehow find they
cannot. Motivational interviewing (MI) aims to help individuals explore and
resolve the discrepancy between where they are and where they want to be in
relation to their health behaviour. A collaborative conversation style of consult-
ing is used to strengthen someone’s motivation and com- mitment to change
(Miller & Rollnick, 2012). It is part of an integrated approach, rather than a
standalone therapy, and consists of a range of therapeutic strategies, which are
underpinned by a person centred approach. The use of high level interpersonal
skills in this context enables the client to build commitment and reach a decision
to change if that is appropriate for them (Miller & Rollnick, 2012; Rollnick et al.,
1992).

Behaviour therapy

Behaviour therapy or behaviour modification helps clients to identify unhelpful

behavioural patterns and develop ways of modifying these. A wide range of
practical behav- iour modification strategies are commonly used in dietet- ics that
help clients manage eating and activity behaviours (Pearson & Grace, 2012), as
shown in Box 1.3.2.

Cognitive behaviour therapy

Cognitive behaviour therapy includes behaviour modifi- cation strategies as well

as cognitive restructuring. Cogni- tive restructuring aims to help clients identify
and then change unhelpful thoughts, ideas and beliefs that might maintain
undesirable behaviours. The application of these approaches to dietetic practice
has been described and explored by Rapoport (1998). It is essential that
appropriate clinical supervision is in place for practition- ers using this approach.

Guiding principles

Health professionals ideally base their practice on under- lying principles, ethics
and beliefs (see Chapter 1.1). Good communication skills play a major role in the
outcome of a consultation and underlying these skills are principles that motivate
or guide the practitioner and influence the way they apply any skills they may
have acquired. These guiding principles provide a foundation for any model,
theory or skills that are used. In an inte- grated approach they include the
following:

Person centred approach

A person centred approach forms the basis of the helping relationship. Rogers
(1951) described the essential core conditions that need to be present in order to
work in a person centred way: empathy, genuineness and acceptance.

Empathy

Empathy involves caring in a truly genuine and accepting way, and developing a
sensitive and accurate understand- ing of the way in which the client perceives
their experi- ence. An empathic person shares another person’s experience as if it
were their own, whilst being aware throughout that it is not. Clients feel they have
been heard and understood.

Genuineness (congruence)

Genuineness is important for the formation of a helping relationship, which is built

on trust. It means being who we truly are, being honest and matching what we say
with how we say it, both verbally and non-verbally.

Acceptance (unconditional positive regard)

Acceptance means having respect for another as a human being, regardless of who
they are or what they have done. This means accepting the cleint unconditionally
without condoning and being judgemental. Health professionals need to guard
against forming judgements about clients who do not adhere to recommended
treatment and to seek to understand the client’s perspective rather than label them
as non-compliant.

The core conditions are often difficult to adhere to but their importance highlights
the need for continual reflec- tive practice. When consultations do not go well, a
natural response is to blame the client as being difficult, but it may be more
productive to reflect and consider if any of the core conditions were absent.

Respecting client autonomy

This is a key element of facilitating health behaviour change; it is accepting the

right of the individual to make choices about their own actions. Practitioners need
to resist the urge to tell people what to do, in the belief that they know what is
best. Experience and expertise need to be shared in a collaborative way in order to
achieve the best outcomes, with clients being fully involved in any decisions.

Box 1.3.2 Examples of behavioural strategies used in dietetic practice

• Do nothing else whilst eating; sit down at a table • Do not eat when watching TV
or reading• Chew each mouthful thoroughly• Put your knife and fork down
between mouthfuls • Use a smaller plate or bowl

• Put food away – out of sight• Plan menus for the week ahead• Always shop from
a list• Never shop on an empty stomach• Do not sit for longer than 30 minutes •
Plan activity for the week ahead

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28

Section 1: Dietetic practice

Client responsibility

This principle acknowledges that people are responsible for their own actions.
Practitioners need to try to under- stand the difficulties that people experience with
change, whilst at the same time respecting client autonomy.

Social influence

Dietitians have a remit to influence health behaviour and this influence can be very
powerful, even when time is limited. Practitioners can sometimes feel that the
situa- tion is hopeless when the client has multiple problems, e.g. poor
relationships, low income and poor health. It is important to remember that
everybody has the ability to change (Miller & Rollnick, 2012); although not
everyone will change, they may be able to take some steps towards improving
their health.

Collaboration

The principle of collaboration helps to accommodate both the client’s and the
healthcare professional’s agenda. It recognises that two parties with expertise have
met; one with expertise about themselves (the client) and one with expertise in the
topic area, along with specific helping skills (the healthcare professional). A
collabora- tive helping relationship is built on trust and mutual respect; it considers
both parties as equals in exploring the possibilities for change (Pearson, 2010).

Self efficacy

In order to change people need to believe that change is possible. The task of the
practitioner is to help people develop self belief in their ability to make changes.
This can be achieved by helping to build the client’s confi- dence and competence
(Bandura, 1977).

Empowerment

Empowerment for health is a process through which people gain greater control
over decisions and actions affecting their health. This principle has especially
influ- enced the development of care offered in diabetes man- agement (Funnell &
Anderson, 2003). It recognises that clients are in control of and responsible for the
daily self management of their health and that, to succeed, a self management plan
has to fit clients’ goals, priorities and lifestyle, as well as health problems.

The client centred method

The client centred clinical method (which includes many of the above elements)
was developed by Stewart (1995) to address the limitations of the biomedical
model. It includes the conventional biomedical approach but extends it to include
consideration of the client as a person. The model consists of six interconnecting
components:

• Explore both the disease and the illness experience. • Understand the whole
person.• Find common ground.• Incorporate prevention and health promotion.

• Enhance the client–practitioner relationship. • Be realistic.

A client centred approach has been shown to be associ- ated with improved health
status and increased efficacy of care (Stewart et al., 2000).
Communication skills

Effective client care relies heavily on good communica- tion skills that can be
applied in any setting, e.g. during consultations and when discussing client care
with medical staff, relatives, administrators, etc. These skills may be variably
described as counselling, consultation, interviewing, active listening, reflective
listening and com- munication or interpersonal skills. Many dietitians are naturally
good listeners while others develop their listen- ing skills through years of
practice. These skills must be continually developed and refined. Using these
skills throughout the consultation can have an enormous impact on facilitating
health behaviour change.

There is evidence to support the use of communication skills. Najavits & Weiss
(1994) reported that the single most important factor that influences change is the
prac- titioner’s possession of strong communication skills. The health
practitioner’s way of working or therapeutic style can strongly influence the
intervention outcome (Miller & Rollnick, 2012). Stewart (1995) showed a positive
and significant relationship between communication and client health outcomes,
concluding that ‘good communi- cation is good evidence-based medicine’.

Attending behaviour

Actively listening to another person, both verbally and non-verbally, conveys

acceptance. Attending also involves being aware of personal verbal and non-verbal
behaviour, which reflects personal thoughts, feelings and attitudes.

Non-verbal communication

In addition to words, non-verbal communication gives very powerful messages

and may account for as much as 85% of communication (Ivey et al., 1997). The
practi- tioner should also observe clients’ non-verbal cues. Important aspects of
non-verbal communication include:

• Body language that is appropriate to the context of the conversation. An open,

relaxed posture and leaning slightly forward is generally recommended, rather
than an unnatural or stiff posture. It is also important to avoid distracting
behaviours such as constant nodding, fiddling with pens or looking at a watch.
Hand move- ments are a normal part of non-verbal communication, but they
should not be invasive. Sitting at an appropri- ate distance so as not to invade the
other person’s space, but equally, not too far away, should be taken into
consideration.

• Eye contact that is varied and non-staring.• Facial expressions that convey
empathy and provide encouragement, e.g. an encouraging smile or nod. Facial
expressions need to match the mood of the con- versation, e.g. not smiling when
the person is describ-

ing something sad.• Pace of an interview. Rushed consultations can leave

the client feeling confused or unsure about what has

SECTION 1

1.3 Changing health behaviour

29

been discussed. It is important to allow time for clients (and practitioners) to think
clearly and express their thoughts; a brief silence or a pause can help achieve this.

• Tone of voice and general demeanour make a differ- ence to the meaning of what
is said and its interpreta- tion. It is important for dietitians to take note of these
factors as clients may be communicating something different from the actual
words that are being said. Dietitians also need to be aware that their tone of voice
and body language can convey meaning in either a more or less helpful way, e.g.
disapproval or encouragement.

Practitioners need to be familiar with and take into account cultural differences,
along with the age and gender of the person. Disabilities such as hearing, sight or
cognitive impairment will also impact on communication.

Minimal encouragers

These are used to indicate to clients that they are being actively listened to and to
encourage them to talk. They can include non-verbal language such as nodding, an
encouraging smile, or minimal utterances, e.g. ‘mm, mm’, ‘ah hah’, ‘and’,
‘so . . .’. Finding the right balance of how and when to use (and not to overuse)
minimal encourag- ers is a skill that needs practise. Some words used in everyday
conversations such as ‘right’ and ‘ok’ can convey the wrong meaning or become
irritating if constantly repeated throughout the conversation.

Verbal following or restating

This consists of a word, a phrase or a sentence (some- times phrased as a question)

that repeats what has just been said (although not verbatim). For example:

Client: ‘I’m really struggling to fit this diet in with the rest of the family.’Dietitian:
‘‘Family?’ or ‘You are struggling to fit the diet in with the family.’

Client: ‘Yes, they all like . . .’

It encourages the person to expand on what they have said; it needs to be used
skilfully without overuse, but combined with other skills to convey accurate
empathy.

Paraphrasing

Paraphrasing is the skill of rephrasing that conveys the factual essence of what has
been said and is used to reflect back the essence of the conversation in ‘pieces’ of
content For example:

Client: ‘This diet is just too hard to follow when I’m eating out.’Dietitian: ‘You are
struggling to manage with eating when you are not at home . . .’

To be effective, a paraphrase requires a level of accuracy that helps provide clarity

for both the client and practi- tioner. A paraphrase should be used tentatively so
that the client can agree or correct any inaccuracies. A succinct

accurate paraphrase is very powerful in helping clients feel understood.

Reflecting feelings

A reflection of feeling conveys to the client that the prac- titioner is trying to
understand what they are experienc- ing emotionally. People can show their
feelings in different ways: verbally, non-verbally or a combination of both. Asking
people how they feel is not always helpful as people can struggle to express their
emotions, so avoid ‘How do you feel?’ It is more useful to reflect tentatively and at
the right intensity what the person appears to be experiencing. For example:

Client: ‘And then he told me that I have got diabetes!’ Dietitian: ‘It sounds as if the news
was upsetting for you . . .’

Many dietitians are wary of addressing feelings but to neglect how people are
feeling in relation to their health is missing a vital element of what is likely to
influence their behaviour. However, dietitians need to recognise their limitations
in this area and to know when and how to refer on when appropriate.

Questions

Questions are useful for eliciting important information. Closed questions are an
efficient way for gathering spe- cific information, e.g. ‘Do you take milk in your
tea?’ whereas an open question encourages the client to explain things from their
perspective, e.g. ‘Can you fill me in on what led up to your doctor suggesting you
come to see me?’ Most consultations require a combination of open and closed
questions. However, questions need to be used selectively to avoid what can feel
like an inter- rogation. In general, ask open questions (unless specific information
is required), avoid asking two questions in a row and for every question, offer at
least two responses (Rollnick et al., 2008).

Summarising

Summarising helps to pull things together at different points in the consultation

and is especially useful at the beginning and end of the session. Short summaries
help to clarify the situation as the consultation proceeds. For example:

Dietitian: ‘Can I check what we have covered so far? You went to see the doctor because
you were feeling unwell and the result of all the tests was that he told you that you have
diabetes, which was unexpected and the news has left you feeling upset and worried. Is
that right? (Pause).

Is there anything else?’

Longer summaries may be needed to clarify long and complicated stories as they
provide a pause, time to think and help give direction on what to focus on next.
Sum- maries are also useful to help dietitians remember what needs to be recorded
in the notes.

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Section 1: Dietetic practice

Potential pitfalls for practitioners

Dietitians and health professionals often feel they have an obligation to make their
clients change – we cannot make people change. Despite the best of intentions,
this can get in the way of facilitating change. In an integrated approach, the
dietitian aims to enable the client to choose and implement changes to their health
related behaviour. Anything that results in the client feeling disempowered or
criticised may inhibit this process and can be a poten- tial pitfall. Examples of
common pitfalls are:

• Trying to persuade or force clients to change, e.g. ‘Your blood pressure is

raised; you really must make some lifestyle changes . . .’ Using pressure to
try and con- vince or persuade someone to change assumes that the
practitioner knows best about what the person should do. If a person feels
under pressure, they are less likely to be able to make a free choice.

• Trying to solve the problem, e.g. ‘What I think you need

todoiscutoutchocolateandgowalkinginstead’. This is often portrayed as well
meaning advice or a solution offered from the practitioner’s point of view.
 In prac- tice, however, clients are their own experts and are best at finding a
solution that will work for them. They may need some guidance from the
practitioner but this does not mean that the practitioner should lead or
dictate rather than facilitate.

• Underplaying the real health risks, e.g. ‘The situation could be worse . . .’ This
may take the form of trying to appease clients. It arises from an apparent
desire to protect clients and is often due to fear of upsetting them or a fear
of not knowing how to cope with a cli- ent’s distress if they become upset.
How information about health risks is presented is of vital importance.

• Presenting information in a threatening manner, e.g. ‘If you don’t lower your
cholesterol, you risk getting . . .’ Fear can motivate some people, but others
may become defensive as a result.

• Hiding behind or dictating policy, e.g. ‘If you don’t lose more than a couple of
pounds by your next appointment you will be discharged’. This strategy
may be an attempt to control caseload by discharging anyone who is not
succeeding according to a predeter- mined specification, but in practice is
likely to reinforce a person’s sense of failure and may exert unrealistic
pressure. Policies need to incorporate negotiation and flexibility.

• Interrogating, e.g. ‘Why didn’t you follow your eating plan?’ This is difficult to
answer and may make clients defensive. Asking lots of questions, often in a
desire to get to the heart of the problem so that it can be ‘fixed’, or to try to
get the client to ‘tell the truth’ is counter- productive. It does not encourage
clients to talk openly as the agenda is practitioner led and can close down
the conversation.

• Blaming or judging, e.g. ‘You must be eating more than you have said or you
would have lost weight’. This assumes that the client is lying and that the
practitioner knows better than the client.

Ongoing practitioner development

In psychology and counselling, practitioners routinely receive supervision on

developing their own responses and understanding, as well as improving how they
work with their clients. This is not generally the case with other health
professionals. It is unrealistic to expect anyone to be totally empathic,
unconditionally accepting and genu- inely collaborative, and also free from
judgement, blame and criticism and the desire to want to rescue, protect or fix it
for their clients. Although dietitians can aspire to these qualities, they are not
necessarily present. Some elements can be acquired through skills training and can
be further enhanced through self development (Gable, 1997). Ongoing self
evaluation, developing self aware- ness and life management skills can all help
this process. Regular supervision is essential and all health profession- als should
be involved in ongoing self development as an essential foundation to their
practice and as part of con- tinuing professional development (see Chapter 1.2).

The dietetic consultation in practice

Setting

A dietetic consultation has the explicit intention of dis- cussing the person’s diet in
relation to their health. It is clearly very different from an informal meeting and
there- fore needs to operate within certain boundaries, but should not be so formal
that the client feels uncomfort- able. The environment, or setting, in which people
are seen needs careful consideration. Is the waiting room arranged in a way that is
welcoming, with suitable seating and reading material? Is the consultation room
arranged in the best way? Has clutter been removed and telephones or other
interruptions been diverted? The dietitian (as the client’s advocate) has a
professional responsibility to seek optimal consultation settings.

Proposed framework for the consultation

The dietetic consultation is made up of a series of differ- ent elements. Suggested

frameworks for an initial and follow-up consultation are shown in Figure 1.3.1 and
Figure 1.3.2. These should be flexible with different ele- ments being applied
interchangeably within each inter- view, depending on the varying needs of the
client. Not all elements are necessarily included in all interviews, e.g. if someone
is very ambivalent about making changes, the whole of the first session may
involve exploring this. How interpersonal skills link to the elements involved in
the consultation and how to manage difficulties that may arise are explored later. It
is important to be aware of one’s limitations and to refer on appropriately.
Difficul- ties generally outside a dietitian’s expertise include psy- chiatric or
psychological problems, relationship problems, bereavement, stress, social and
economic problems, and problems that are more properly the remit of other health
professionals, e.g. speech and language therapists.

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1.3 Changing health behaviour

31

Meet and greet

Assess the overall situation

(Current scenario, motivation, clinical and medical history, anthropometry, etc., psychosocial
position, difficulties, expectations, current lifestyle)

Figure 1.3.1

Explore options for change

Negotiate goals and develop a change plan

Identify and implement rewards

Build social support

Selfmonitoring, reviewing and adapting change plan accordingly

End interview

giving an indication of their understanding of the reason for the referral. For
example:

‘Your doctor has written and asked me to see you. Would you like to tell me what has
been happening from your point of view that has led up to this?’

Or for a review appointment:‘How have things been going since we last met?’

Assessing the overall picture

Assessment is standard practice and is likely to take up most of the first

consultation, but it also needs to con- tinue throughout further consultations as
change takes place. It needs to be undertaken in a collaborative manner so that a
true picture of the person’s situation emerges. Subsequent treatment goals can then
be tailored to the individual with the ultimate target of achieving better health
outcomes. The initial assessment needs to include the overall clinical and medical
situation as well as the client’s experiences and circumstances. For example:

A suggested framework for an initial dietetic consultation