Tara MacGregor PACFA Reg Clinical 21520 & APD

A couple of years ago, when preparing for a Motivational Interviewing Seminar, I was listening to a webinar by Dr Ellen Glovsky RD and I had to laugh out loud when she said:

‘After 20 years of practice…I began to notice that almost NO ONE who I had asked to make changes to their diet over the 20 years I had been working had actually made those changes that I had recommended!’

I laughed heartily, not at Ellen but at the stark bold truth in what she was saying. It was spot on (and promptly received its own dedicated slide in my seminar). In her webinar Ellen goes on to comment on how discouraging it is to be well intentioned, highly educated and hardworking and not be able to make a lasting difference to people’s well-being. I’m with you Ellen!

As APD’s we are comprehensively trained in the Medical Model. Of course this has great merit in imparting the importance of scientific rigour and knowledgeable expertise. For those of us working in the area of nutritional science, the medical model is an important paradigm.

For those of us working in helping people with eating behaviours (most of us out there) the Medical Model gives us a square peg for a round hole. If eating behaviour change is your area, I am sure that you have discovered yourself that clients who feel overwhelmed, ambivalent, stuck or a failure benefit little from ‘being educated’.  The evidence base for Motivational Interviewing across a broad spectrum of clinical areas is coming in with a resounding message: traditional advisory counselling promoted in the medical model can be a profound impediment to helping people.

So the question must be asked – is it the model we are using to facilitate change in our clients a big part of why our clients may struggle with change? Are WE part of the problem?

Let’s have a quick look at the two models.

The Medical Model

The Medical Model is based on the premise of ‘expertise and deficit’. It works a bit like this – the ‘patient’ has some sort of deficit (knowledge typically) and our expertise is just the ticket to help them out. There is an assessment process leading to a diagnosis and then we ‘press download’ for the prescription which is usually given as some form of education. OK, so I’m overlooking some of our professional finessing here for the sake of brevity but you get the gist!

The experience for many of our clients of the Medical Model – particularly as mentioned the stuck, overwhelmed and ambivalent, is typically not so great. The dynamics between the practitioner and client in this model set the client up to often feel over-looked, judged or powerless. This model really betrays our best intentions to be helpful. No one wins.

As APD’s we all have our ‘inner white coat’ and our tertiary training (and for some – our workplace), applauds and rewards us to put this coat on. It can feel safe and even a bit special to be an expert. On the flip side, it can also be an extraordinary strain to need to know what’s best for another human being and to have access to all the answers that will be the right fit for an infinite variety of individuals. Burn out is becoming more recognised in our profession, featuring recently in a Dietitians Association of Australia webinar. In my own personal experience and also the experiences I debrief with supervisees and the many training groups I have facilitated for APDs since 2014, the pressures of the medical model contributes hugely to our burn out risk.

So it is becoming clearer for a large cohort of our clients the expert Medical Model doesn’t work so well AND we may not fare so well with it either. Whilst this may be a confronting acknowledgement there is hope – there is a better way to deliver our professional guidance that cares for both the practitioner and the client in one.

The Client Centred Model

The Client Centred Model is based on the work of Dr Carl Rogers a Psychologist and Researcher who’s work in the 1950’s and 60’s was a core piece in a new wave of thinking that changed psychotherapy for ever. A mirror for the social changes at the time, Roger’s work challenged psychological thinking to embrace the resources of the client as the most productive way (for all concerned) to work with a fellow human being.

There are parallels for us as Dietitians in this transformation of psychotherapeutic practice even though there are of course distinctions between the two professions. Psychological therapies prior to the client centred influence were dominated by the medical/psychoanalytical model. Much like where Dietetics is emerging from today, the psychoanalytic model took a diagnostic stance towards ‘patients’ seeking help and this help was categorised as expertise that would ‘repair’ or ‘cure’ the patient. Sound familiar?

Research in Canada has suggested that Dietitians like the idea of the Client Centred Model (makes sense – we want to be helpful!) but don’t really know how to do it (makes even more sense as few of us are taught it!). In Australia there is a growing interest in Dietetics in client centred paradigms including Non-Diet approaches, Intuitive and Mindful Eating.

This is one of my favourite quotes explaining the client centred philosophy:

‘People are trustworthy, resourceful, capable of self-understanding and self-direction, able to make constructive changes and able to live effective and constructive lives……….if provided the right climate people can move forward and become what they are capable of becoming.’ Corey G

Our job in the Client Centred Model is to provide this ‘right climate’. This is experienced by the client as a climate in which they are understood, valued and trusted. This requires a new stance from the expert/deficit dynamic of the Medical Model.  This stance is one in which the Dietitian sits alongside the client and learns first from the client before they press the download button …. (in this process the APD may discover there is nothing to download that the client doesn’t already know!). It is a stance where the client is privileged as the expert in their own lives. It is a stance that distinguishes this expertise from our expertise in nutrition.

Our job in the Client Centred Model is to discover how the client may want to use our expertise in nutrition, how they want us to deliver that information and how they want us to support them to make change they value within the context of their lives. This requires a new skill set to complement our stance.

Working with BOTH Models

It would be overly simplistic and somewhat naïve to assert the way forward is a simple paradigm swap from medical to client centred. The real change required is a skilful and delicate dance, one which I believe as a profession we are entirely capable of making. I would also argue this is a change we have to make to remain progressive, evidence based and relevant in a very competitive market place. I’ll leave you with another favourite quote to get you thinking……..

“The test of a first-rate intelligence is the ability to hold two

opposed ideas in the mind at the same time and still retain the ability to function.”

F. Scott Fitzgerald

Looking for Support to Skill up in this Area?

Practice Pavestones runs regular training supporting health professionals develop skill for effective behaviour change counselling within the client centred model. Feel free to email Tara with any questions.

About the Author

Tara MacGregor is a professional Counsellor & Psychotherapist and Accredited Practising Dietitian with a private practice in Sydney.