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question is how do you help clients weed through the mess of misinformation without making them feel judged or belittled?
Some health professionals take it personally when clients ask questions about fad diets or show attachment to certain diet rules not based on sound science. In these situations, it’s tempting for the health professional to scoff at the behavior. He or she may say something like, “That doesn’t make any sense” and expect the client to dismiss the diet or product and move on to something more productive. Although the client may say nothing, he ends up feeling embarrassed and judged, and just when he was really beginning to like and trust his nutrition counselor.
There are so many possible topics to discuss in nutrition and fitness
counseling. From the very beginning, clients are sometimes apprehensive about what they will be asked to change. An MI practitioner isn’t going to prescribe certain lifestyle changes because it forces the client into a passive role in the behavior change process, but the client may not be aware of that in the beginning. Instead, the practitioner is going to elicit what the client is interested in exploring, what information gaps may be present, or what specific problems the client is struggling with. Therefore, the practitioner walks alongside the client and gently guides him or her through ambivalence and toward change.
It’s important to be mindful of your own agenda when first entering
an appointment. Letting go of your own agenda isn’t the same as having
no focus or direction within the process of change; quite the contrary.
However, with every client, you enter into a partnership where your role is to see the problem through the eyes of the client, rather than through your own.
A guiding style allows both the practitioner and the client to negotiate the agenda. If the client is misinformed about a topic, she likely is unaware that her facts are incorrect. Clarifying the misinformation will understandably not be one of her goals for the appointment. When using a guiding
style, the practitioner prioritizes what the client wants to talk about and may offer clarification for the misinformation voiced by the client.
You may detect beliefs based on misinformation within the first few
minutes of a session. If you respond
by immediately correcting the client
You may detect beliefs based
you may set the stage for increased
on misinformation within the
sustain talk and discord. While he
first few minutes of a session.
or she may be impressed with your
If you respond by immediately
knowledge of the scientific literature,
correcting the client you may set
you also risk coming across as arro-
the stage for increased sustain
gant and unapproachable. Here are
talk and discord.
some strategies for correcting mis-
information while at the same time
emphasizing client autonomy.
Health Misinformation and Unhealthy Beliefs 177
resIstIng the rIghtIng reFlex
The righting reflex is the temptation to provide unsolicited advice or information that corrects something perceived as wrong in the client’s statement. It’s important to tame the righting reflex when you hear misinformation and instead respond with compassion, respect, and an overall sense of curiosity. Consider the following interactions. The first dialogue showcases Practitioner A, a diabetes educator. He starts off on the right track but is thrown off course when he hears the client voice incorrect nutrition information.
pRactitioneR A: What do you typically drink? How do you stay
hydrated?
client: I usually drink juice. Juice doesn’t have sugar in it. It’s natural.
pRactitioneR a: Oh no. Where did you hear that? Juice may have
natural sugar, but it’s still sugar. The first thing I want you to do
when you get home is to throw out the juice. Do you think you
can do that?
client: I don’t know.
The urge to quickly and concisely correct clients may surface when you
hear them repeat incorrect information. You may believe it is your duty to correct misinformation and provide advice. With MI, however, the purpose is not to give advice. The purpose is to cultivate change. Practitioner A may have fulfilled his need to provide information but he will be woefully ineffective at meeting the needs of the client.
Alternatively, Practitioner B is not caught off guard when hearing mis-
information. He remembers to reflect and ask permission before providing a small amount of information, and then checks in with the client.
pRactitioneR B: What do you typically drink? How do you stay
hydrated? [open-ended question]
client: I usually drink juice. Juice doesn’t have sugar in it. It’s natural.
pRactitioneR: It’s important to you to make food choices that
improve your health and well-being. [affirmation] I wonder if it’d
be helpful if we talked a little about sugar and where it’s found in
foods. [asking permission]
client: OK.
pRactitioneR B: Sugar comes in many forms. It can be in the form
of table sugar or corn syrup, and it can also be less visible. Fruit
contains a natural form of sugar that is also found in juice. In
100% fruit juice the sugar is not processed or added, but it still
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greatly affects one’s blood sugar. [provide] What do you make of this information? [elicit]
client: I didn’t realize that.
pRactitioneR B: Considering this information, I wonder if the juice
you’re drinking is driving your blood sugars up. What do you
think? [Elicit]
Practitioner B has a much better chance of influencing the client
because of the respectful manner in which she communicates. By asking
permission and eliciting how the client responds to the information, the practitioner supports client autonomy. The practitioner prioritizes the client’s needs over her own.
ProvIdIng InForMAtIon usIng elIcIt–ProvIde–elIcIt
People have all sorts of beliefs about food, how to eat, when to eat, and what to eat. These types of food-related beliefs have been passed down from one generation to another since the beginning of humanity and change as life’s circumstances change. Many beliefs about food and eating come from the
caregivers in a family. Mothers and grandmothers have a particular impact on one’s eating habits. “Always eat your vegetables” or “Clean your plate”
are common phrases at the dinner table. Some of this advice is helpful; some is not.
In addition to caregivers, food and eating advice comes from people
of perceived authority in health and wellness. Doctors, health coaches, and anyone who publishes a book on the subject have an impact on what people believe about food. Nutritionists are constantly asked which diet rules are fact and which are fiction. Entire TV shows are dedicated to issuing food rules to help people lose weight or cure ailments. The principles of information exchange from Chapter 5 apply when correcting false information.
Elicit–provide–elicit (E-P-E) is a useful tool for gently pointing clients in the right direction.
elicit
Elicit before providing information contrary to what the client thinks. The purpose is to gain permission, assess prior knowledge, or gauge overall concerns or interests in the topic. In the previous scenario about juice, the practitioner first asks permission before talking about where sugar is found:
Health Misinformation and Unhealthy Beliefs 179
“It’s important to you to make food choices that improve your health
and well-being. [a
ffirmation] I wonder if it’d be OK with you if I talk a little about sugar and where it’s found in foods. [asking permission]”
In another scenario, the practitioner assesses the client’s knowledge
about foods high in sodium by asking an open-ended question in a non-
judgmental way:
“You have been trying to control your blood pressure by eating less salt.
What kinds of foods strike you as being particularly high in salt?”
In the next scenario, the practitioner assesses the client’s concerns
about diet pills before providing information:
“You’re interested in taking the diet pills your mother gave you. What
concerns do you have, if any, about taking them?”
This last scenario gauges the client’s interest level by using an agenda-mapping exercise to focus the conversation:
“You’ve mentioned a few things this morning and I wonder which is
more important to you to talk about today. Earlier, you said you’ve
been making your son, Sam, whole-grain breakfast pastries in the
morning because they’re fast, he likes them, and you’re thinking the
whole grain makes them a good breakfast. I could offer you some
healthy, quick breakfast ideas if it would be useful to give you a little variety. You’ve also said that you’re concerned about your son overeating when he is at his dad’s house and he seems to be making unbal-
anced snack choices in the afternoon. Which, if any, of these topics
would you like to focus on today?”
Before providing any information to a client, whether it is novel or
clarifying, harness the spirit of MI and first ask permission. Remember, it is completely within your client’s right to refuse this information. A refusal may not be a straightforward “no” but simply a shift to a different subject, or the client may speak as if you hadn’t said anything at all. Take these subtle hints as a polite way of saying, “No thank you, I’d rather keep talking about this now.”
Provide
As with usual information exchange, clarifying health misinformation
requires the practitioner to lay important groundwork before providing
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information. Once that’s done, though, it’s time to share the information you have with your client. Here are four tips to keep in mind when providing information.
Provide Only Relevant Information
The client gave you permission to talk about a specific topic, not to ramble on or shift to another topic entirely. Stay on topic and only provide information that is relevant to the situation. Health practitioners have a tendency to tell their personal experiences as a way of relating to and motivating their clients. Especially in health counseling, it’s common to find practitioners who have struggled and succeeded with their own health challenges.
Self-disclosure can be a powerful way to tell clients they are not alone and you truly understand their challenges on a personal level. However, it can easily switch gears into a conversation about the practitioner and not the client. If you decide self-disclosure is appropriate, keep it relevant to the client’s issue and make every effort to see the circumstance through the eyes of client and not through your own experience. Just because your experience was similar does not mean it is the same.
Keep It Short
Information overload can happen when a practitioner monopolizes the conversation. Although it may be pertinent, clients become disengaged when the practitioner becomes long winded in her explanation. Focus on clear and concise explanations that engage the client.
Use Understandable Terms
Medical terminology was developed for practitioners to easily communi-
cate with one another. Latin root words are further described with pre-
fixes and suffixes that fully explain the treatment, procedure, disease, or condition. Although useful in the medical field, medical terminology has a way of dismantling the client–counselor relationship by making the counselor assume the expert role.
Medical terminology belongs in the
Although useful in the medical
client’s medical chart, not in the
field, medical terminology has a
information exchange between client
way of dismantling the client–
and practitioner. Support the client’s
counselor relationship by making
role as the expert by using commonly
the counselor assume the expert
understood words, such as those
role.
listed in Figure 12.1.
Health Misinformation and Unhealthy Beliefs 181
avoid
use instead
• Sodium
• Salt
• Hyperglycemia
• High blood sugar
• Neuropathy
• Numbness and tingling
• Triglyceride
• Fat in the blood
• Anaphylactic shock
• To stop breathing entirely
• Myocardial infarction
• Heart attack
• Cholecystectomy
• Gal bladder removal
FIgure 12.1. Examples of medical terms to avoid when speaking with clients.
Use Language That Supports Client Autonomy
In the scenario below, Practitioner A provides an example of what not to do.
In the scenario, the practitioner is talking to an insulin-dependent diabetic who is hospitalized after accidently taking too much insulin. The practitioner has seen the client for outpatient diabetes education prior to the incident, but the client is still figuring out how to best manage her blood sugars.
“I know you know this stuff. We’ve gone over this. You know you must
test your blood sugar before meals. Then you have to count the number
of carbohydrates you’re about to eat and give yourself the correct amount of insulin. Each 15-gram serving requires 1 unit of insulin coverage. If you continue on this path I’m afraid you’re going to kill yourself.”
By using such confrontational language, the practitioner risks making
the client feel ashamed for not dosing her insulin properly. By using the terms “you must” and “you have to” the practitioner essentially removes client autonomy entirely. Saying, “I know you know this stuff” makes the client feel put down, as if she intentionally disappointed her counselor. To finish it off, the counselor uses highly inflammatory rhetoric intended to scare the client into compliance. This type of scare tactic can easily backfire, leaving the client feeling hopeless and unmotivated. Alternatively, Practitioner B uses language that supports client autonomy.
“If it’s OK with you, we can review your insulin treatment plan and see if something needs to be adjusted. You’re on a carbohydrate-counting
insulin treatment plan, which works by using two types of insulin.
Ten units of Lantus is given each night and Humalog is injected before
eating carbohydrates. The dose of Humalog depends on the number
of grams of carbohydrates you plan to eat. This type of insulin works
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best if 1 unit is injected for each 15-gram serving of carbohydrates
eaten. If taken incorrectly, too much insulin causes the type of black-
out episode you had yesterday.”
In the second scenario, the practitioner provides the information as
objectively as possible, after asking permission. She leaves out “you must”
and “you are supposed to.” In fact, she omits the word “you” altogether.
By using such neutral language, the client is left to decide what she’ll do from here.
elicit
Finish an information exchange by asking the client what she thinks or how sh
e feels about the information. Here are some examples of a final elicit:
“What do you think?”
“What do you make of all this?”
“I wonder what your reaction is to this.”
“How would that work for you?”
“What else would you like to know about how this works?”
You can also reflect the client’s nonverbal cues as a way to elicit a
response.
“You look confused. What can I make clearer?”
“This information seems to have upset you. What part do you disagree
with?”
“That seems to have resonated with you. Which part did you like?”
E-P-E is a useful tool when attempting to correct misinformation
because it allows the practitioner to assess the client’s understanding before providing information, while at the same time promoting consistent interaction and engagement. A summary of the E-P-E technique for correcting
misinformation is provided in Figure 12.2.
Clarifying misinformation requires the practitioner to provide infor-
mation contrary to what the client already thinks or believes is correct.
In order to provide this information in a respectful way the practitioner uses the same principles of information exchange with new information.
Elicit the client’s understanding of the information, gauge interest in having the information corrected, and ask permission to provide it. Then proceed with presenting the information using language that supports autonomy
and avoids information overload. Close your presentation by eliciting the client’s response with true curiosity for her perspective and its potential effect on her decision moving forward. Misinformation not only comes
Health Misinformation and Unhealthy Beliefs 183
Elicit
• Assess for information gaps, gauge interest, or ask permission.
• “What foods strike you as being particularly high in sugar?”
• “What would you like to talk about today? We could review foods high in carbohydrates, your target blood sugar ranges, symptoms of high and low blood sugar, or another topic.”
Motivational Interviewing in Nutrition and Fitness Page 24