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Make Effective Connections — Key Strategies for Establishing Positive Client Outcomes
By Kate Scarlata, RD, LDN

As consulting practitioners, establishing a positive rapport with our clients is a key ingredient in successful outcomes. Yet creating a constructive connection requires an array of considerations. It’s not just about teaching everything we know. (And yes, we all know a lot!) It is less about what we say and more about how we say it.

Effective counseling should incorporate the following: creating rapport, fine-tuning listening skills, using motivational interviewing (MI) techniques, and finding an effective educational approach.

Establish Rapport
How do you establish rapport with your clients? Create a warm welcome by smiling and establishing eye contact when you first meet. Try to imagine that you are connecting with a good friend. Being courteous, respectful, and unrushed helps create a better tone for your meeting. It’s not uncommon for clients to feel as though they have failed their health goals when they walk through your door, so do your best to reassure them that you can start them on the right path.

Taking time to create a positive relationship with clients will pay off. Jerome Shore of the Coaching Clinic, a seminar where managers and other leaders learn crucial coaching skills, states, “The way to think about rapport is as an investment. The more one invests in building rapport, the more progress they can make in a relationship. As a coach, I know that the more I can build rapport with my clients, the easier it will be for them to learn about and accept what they need to do to move towards their goals. With less rapport, every step is more burdensome.”

Obstacles to establishing rapport have emerged due to burgeoning technologies and online charting. Can you listen attentively while typing on a computer? Can you exhibit empathy when you are not looking at the person but at a computer screen? As healthcare has become more business focused with financial outcome pressures, patients are often limited to shorter and more rushed visits. How can patients feel at ease if the practitioner is hurrying them out the door? Be cognizant of how you appear to your client so that you create a pleasant experience. Simply asking the client what name they would like to be called can be comforting. Observe nonverbal cues, limit interruptions, and focus on the client.

Finding any commonality that you and your client share may help to foster your relationship. Sophie Kamveris, MS, RD, says, “I connect more easily with patients when there is a common thread amongst us. Perimenopausal and menopausal women and those suffering from IBS [irritable bowel syndrome] seem to melt at ease when they hear that we share many of the same symptoms and struggles.”

Self-disclosure is both the conscious and unconscious act of revealing more about ourselves to others. It can be therapeutic for patients, as it often provides them with a glimmer of hope. If you were able to lose weight or reduce your elevated cholesterol, then maybe they can achieve the same positive results.

If you feel comfortable using this therapeutic approach, self-disclosure can open the door for your patients. If you prefer not getting too personal, try commenting on another shared characteristic or trait. You may share your experience of being a parent, cultural similarities, or possibly a common love for a particular food item. I am married to an Italian man, and my Italian clients love to hear my funny pasta-eating husband stories. Find a simple connection and it will help break down patients’ barriers and allow for more personal and effective outcomes. Kamveris notes, “I think sharing information is an effective bond-building tool.”

Tune Up Those Listening Skills and Use Motivational Interviewing
Establishing yourself as a good listener is also important. Ask questions and listen intently. Listening without judgment is a key concept in MI. Molly Kellogg, RD, LCSW, author of Counseling Tips for Nutrition Therapists: Practice Workbook series, says, “The techniques of motivational interviewing include open-ended questioning and reflecting back what is important to the client. These have the effect of putting the client in a receptive frame of mind and setting the tone for a client-centered process. The style of MI is just as important as the techniques. Rolling with resistance rather than arguing with the client quickly establishes a collaborative relationship. Rapport is a natural by-product of carefully preparing the client for positive change.”

Open-ended questions allow the client to provide more detailed and potentially meaningful information than more focused, close-ended questions. Wait just a little longer than feels natural to give clients time to answer your questions.

Find Effective Teaching Methods
Once you’ve established rapport, it is important to think about our role as practitioners and educators. What is an effective way to teach? Researchers from the University of Oregon have created the following six principles of effective instruction:

1. Primed Background Knowledge: Determine what your clients know about their medical condition before starting the education process. Create a bridge between what they know and what they are about to learn.
2. The Big Idea: Focus on the most basic concepts before advancing to more complex ones. The “big idea,” a notion they will remember for years, is the most important part of the lesson. For example, the big idea for diabetes might be, “It is important to limit carbohydrates to manage diabetes.” Limit the number of new concepts introduced in one lesson.
3. Conspicuous Strategies: Utilize models (eg, food records, computerized food tracking) to teach basic concepts and strategies. Show your clients each step to successfully use these tools. Visual aids (eg, revealing the number of sugar packets in a can of soda) can be powerful.
4. Mediated Scaffolding: When constructing a building, one would use scaffolding for support. Likewise, when teaching, dietitians need to use supports. As you help your client learn more, slowly remove the scaffolding to allow more independent thinking and growth. Help your clients read a food label, pointing out essential components. Next, provide them with a food label and ask questions to evaluate their level of comprehension. Then ask them to bring in a label that demonstrates a healthy choice.
5. Strategic Integration: Introduce more complex concepts as clients understand the basic ones. Link new learning to old and apply learning to other venues so clients can learn how to use the new concepts in every facet of their lives. For instance, once clients understand how to count carbohydrates, help them apply that knowledge to other areas, such as dining out and adapting recipes.
6. Judicious Review: Clients must frequently use what they learn to truly understand the lesson. Follow-up sessions should include the application of concepts to help the client recall previous lessons. Allowing your clients’ level of comprehension to set the pace for the educational process, not arbitrarily written guidelines set in a book, is essential. Review the big idea, gleaning clients’ level of understanding, and determine areas that need further explanation. As clients discuss the big idea, their responses should become more detailed and complex as they integrate the new material they have learned.

Individualize Your Approach
A one-size-fits-all approach to counseling patients is often ineffective. Create an individualized approach while determining whether there are educational limitations, language barriers, cultural differences, or psychosocial obstacles. Include patients’ goals in the therapeutic process. If their referral is for diabetes but they are more focused on weight loss, tailor the education to promote both desirable healthcare endpoints.

You may know what hypercholesterolemia means, but your clients may think you are speaking a foreign language. So remember: It’s not what you say, it’s how you say it.

— Kate Scarlata, RD, LDN, is a private practice nutritionist in Boston and coauthor of the book Real People Need Real Food.