Brittany Rouse

Counseling Paper #2
List of Questions for Each Stage:
Stage 1:

How are you doing today?

How is your anxiety treating you?

Stage 2:

How ready do you feel to incorporate more protein into your diet?
What is a short-term goal we can strive to achieve?
Do you have any barriers that might keep you from succeeding in this goal?
What is the goal, in the long run?

Stage 3:

In the past, what were some ways you managed your anxiety that was
beneficial?
You mentioned you saw a Naturopath, what did they do/say/prescribe that
was beneficial to your anxiety? Did they do/say/prescribe you with anything
unrelated to anxiety that you found to beneficial?

Stage 4:

What are some ways you feel comfortable with increasing protein? Would
incorporating more animal, fish or vegan sources suite you best?

Stage 5:

Are you free next month to talk again, for a third follow-up?

Stage 6:

So, I think what we can do right now is focus on increasing protein and
vitamin D. Does that sound like an achievable, short-term goal?

Stage 1: Re-Introduction of Client

T.J. presents as a 19 year old Caucasian female, weighing 100 pounds and
stands at 55 (yet, I would say she barely breaks 54, since Im 55). BMI is 16.6 (at
54 she is 17.2), but comes from a petite family. She is an Herbal Science major at
Bastyr University. She has a history of drug abuse, irritable bowel and anorexia, but
she has been treated for drug abuse and anorexia.
Some background information: She recalls no allergies or intolerances. She
buys her food at Trader Joes and mainly cooks food for herself, though sometimes
her housemates have potlucks. She has no cultural or religious restrictions. She
does yoga and hikes to manage her stress. The only recent change in her life was

starting college in another state. The reason for the initial visit was because she was
looking for dietary ways to handle her stress and anxiety.
Stage 2: Readiness to Change
Upon looking at her 24-hour dietary recall from session 1, she ingested
around 3,200 calories. A lot of her foods were unique or Trader Joes brands, so it
was difficult to accurately assess her caloric/nutrients intake because a lot of the
food was not on the Food Tracker government website. Going off possible inaccurate
data, her diet consisted mainly of fats (40% of total calories) and carbohydrates
(48% of total calories). She was low in protein (12% of total calories) and low in
Vitamin D (9 g/15 g). I did another 24-hour dietary recall in session 2, just to see
any patterns in her diet. This showed carbohydrates (38% of total calories), fats
(49% of total calories), protein (13% of total calories) and Vitamin D (9 g/15 g),
still low in protein and Vit D and high in fats.
During the first session, we did not go over any goals to achieve by session 2.
I was merely gathering information about my client. But, after going over her first
24-hour recall in session 2, she was amazed to find her fats being so high and her
proteins so low. She figured her Vitamin D would be low because she ran out of her
Lichen pills (as told by my client, they are a natural, algae form of Vitamin D). She
was curious on how to raise her Vitamin D levels with food, instead of pills because
they were expensive. She and I were having fun creating new menu options that
were high in protein and high in Vitamin D. In my opinion, T.J. should be successful
at following her goals we created together because she is loves to try new foods,
loves to make food and is naturally curious about the healing properties of food
(considering she is an herbal science major). Her only barrier being time restraint; if
she can get passed this, she should be just fine.
Stage 2: Main Issues to Work on
Short term goal #1: Increase protein intake by incorporating a 3 oz piece of
meat (poultry, fish or beef) 4/7 days a week.
Short term goal #2: Increase Vitamin D intake by incorporating 2 cups of
mushrooms or 3 oz of salmon 4/7 days a week.
Long term goal: Her long term goal is to reduce anxiety, and better manage
stress, but that is out of my scope of practice. So, I feel that increasing both protein
and Vitamin D levels, in contingence with reducing fat would be the long term as
well. Her diet was fine in everything else.
Stage 3: Possible Solutions
T.J. mentioned in the past she used to be a runner. When she ran, she was
better equipped at handling her stress and anxiety. I told her if it worked in the past,
why give it up? She mentioned time management, and how it is hard to juggle
school, with homework, with studying, with exercising, with making food and with
having a social life. I gave her an option that worked for me, which was create a
daily schedule, penciling in social times, study times, meal times and homework
times. She loved the idea.

For handling time management, I suggested she make large meals during the
weekend (or any day that was best for her to cook) and separate her food in
containers during the week. She then told me she has a roommate in her house that
wanted to start eating healthier. I thought it would be a good idea for her to eat with
her housemate a few times a week, each of them making one thing and eating
together. This could also help with her anxiety; being able to talk about her day, or
vent about any problems shes encountered. This could be therapeutic.
Stage 4: SMART Goals Created and Listed
S: T.J. wants to increase protein because her protein intake was low. She
loves to shop at Trader Joes, so buying protein from Trader Joes would be
best. I even offered the advice of checking Manager Discount meat at QFC.
Sometimes you can get a great deal for protein.
M: Incorporate 1, 3 oz piece of seafood in one meal 4/7 days during the week.
A: I believe this is attainable and realistic.
R: It is important because her protein intake is low. Trader Joes is close to
where she lives, as well as QFC.
T: This wasnt spoken about, but I assumed she would be starting the day we
talked because she was heading to the store to buy food.
- SMART goal: T.J. will increase protein by incorporating at least 1, 3 oz piece of
seafood at any meal during the day, starting today for 4/7 days during the week.
S: T.J wants to increase Vitamin D because her Vitamin D intake was low. She
ran out of her lichen pills (which provided her with a natural form of Vitamin
D). They are really expensive so my client hopes to find dietary ways to
increase her intake. She will try to buy Vitamin D rich foods at Trader Joes or
QFC.
M: Increasing mushrooms (2 cups) or seafood (salmon) in diet (1, 3 oz piece
of seafood) at any meal 4/7 days during the week.
A: I believe this is attainable and realistic.
R: This is important because her Vitamin D levels were low, she does not eat
a lot of foods fortified with Vitamin D, plus she lives in Seattle; very little
sunlight. Trader Joes is close to where she lives, as well as QFC.
T: This wasnt spoken about, but I assumed she would be starting the day we
talked because she was heading to the store to buy food
-SMART goal: T.J. will increase Vitamin D by incorporating at least 1, 3 oz piece of
seafood (salmon or tuna) in diet, or incorporating a total of 2 cups of mushrooms at
any meal, 4/7 days during the week.
Stage 4: Confidence in Carrying Out SMART Goals

I believe these SMART goals are attainable and I feel my client will be able to
meet these goals. I took into account wiggle room, having my client ingest seafood
(to increase protein) 4/7 days as well as ingest mushrooms (to increase Vitamin D)
4/7 days. Another reason I am confident in my client is because of the overlap. If my
client decides to just eat salmon (for example), she will not only increase her
protein, but she will also increase her Vitamin D. Using the ruler, my client gauged
her confidence a 10/10 on protein and Vitamin D.
Stage 4: Strategies to Overcome Barriers
The only barrier my client mentioned was time management. Being a student
and eating healthy can be difficult, especially when there are quicker, more
convenient foods out there; though hardly nutritious. She brought up one of her
housemates is trying to eat healthier, so I suggested she use a buddy system. A
few times a week, T.J. and her housemate can have a meal together, where they
each can cook something. This would save time, and possibly help with her anxiety
(she could talk about her feelings, or vent to her housemate).
Another possible solution to the time management barrier would be to cook
large meals during the weekend (preferably on Sunday), to eat throughout the
week. This would help with time management because she only needs to heat the
food in the microwave, saving time to focus on school. This could also help with her
anxiety because it saves time; she can focus on other priorities that need to get
done.
Yet another possible solution could be her creating a weekly schedule,
penciling in exercising, eating, studying, socializing and homework. This could
alleviate some stress and anxiety.
Stage 5: Educational Material Used
The only educational material I used was the internet. I was showing my
client different foods, as well as their protein content/Vitamin D content. With using
the internet, this allowed me to show her some better, more nutritious foods to
incorporate into her diet, or use as a replacement to current foods in her diet. I also
was able to show her the 24-hour dietary recall, noting the low amount of protein
and Vitamin D in her diet.
Stage 5: Behavioral Contract
I did not use a behavior contract because I could not find this on Moodle.
After searching again (in the hopes of emailing it to my client), it appears I am still
blind and technologically illiterate.
Stage 6: Summarizing and Closing Session
Initially, the appointment was to take an hour, but we overshot by 20 minutes
totaling 1 hour and 20 minutes. My client felt she was able to incorporate more
protein and Vitamin D into her diet. My client loved the idea of the buddy system
and scheduling her week and would start incorporating them into her life. We
agreed to meet for session 3 sometime in March, 2015.

What Worked and What Didnt

I found that having questions written down beforehand and winging it (what I
did in session 1) did not work as well as I hoped. I felt in session 2, I shouldnt write
questions, but rather look over what I needed to do; doing this seemed to work
better. In session 1, I wrote down questions and I felt I was jumping around on
completely different topics, but in session 2, I just laid out categories I wanted to
talk about and it went much smoother. I felt I was better able to listen to my client,
instead of worrying how out of order my questions were. But, it appears I still
winged it, but in a more structured manner. I did not explore the benefits and costs
of change we learned in class as well as her actual relationship with food. Due to my
clients past with anorexia, I did not want to talk about cons of changing her diet as
well as her relationship with food. I felt, if the session took a sharp turn south, I
would not know how to handle the situation. Being that she was treated for her
eating disorder, I did not want to mess any progress made.
Usefulness of Counseling Assessment Checklist
I did not have the Counseling Assessment Checklist with me during session 2
because I do not like having checklists with me when I do a session. I had one
similar with me in session 1, and I focused on making sure I had everything checked
off the list, instead of giving my client full attention. I also found myself trying to put
the sentences into questions (which sounded awkward at best), instead of carrying
on with a conversation with my client. So I tried to look at the list beforehand, and
gauge where the conversation was supposed to go. Doing this really helped me
provide better counseling to my client.

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?
After going over my diet log, I found my protein content was low. Since I dont
eat/drink much dairy, my Vit D was also low. It doesnt help living in Seattle in
the winter months. I guess the take home message is eat more protein and have
more Vitamin D.

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
2

High
6

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?
Nothing I can think of right now.
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 found going over my diet log to be helpful. I liked that Brittany took another
diet recall to get a better diet reading.

5. Overall, rate the quality of this session in terms of its helpfulness.

Low
1

Medium
2

High
6

*Please share any other comments or suggestions below: