Case Studies

Case 2 With a patient: the middle stage of a consultation

This example takes place in a GP practice. 45 minutes are allocated for the appointment.

The patient

Jenny, aged 33, has a body mass index (BMI) of 38 kg/m². She has been referred for weight reduction. This is her first appointment.

The dietitian

Kate is a senior-grade dietitian working in the community.

Summary of the beginning stage

Kate’s first impression of Jenny was of an overweight woman who appeared somewhat dishevelled and had an anxious manner, which led Kate to wonder if she did not care much about the impression she made. Or maybe she simply had too many demands made of her? Even though Kate had already clarified how long they had together and Jenny had nodded in agreement, she still spoke quickly, as though in a great hurry. Kate sensed that Jenny was very anxious.

Kate concentrated on putting Jenny at her ease and explained that she had been asked to assess Jenny’s diet. When asked why she had sought help with her eating, Jenny explained that she had been struggling to control her weight for the past 2 years, since the birth of her second child saying tearfully that she felt fat and disgusting.

Kate discovered that Jenny had returned to hairdressing 18 months ago and enjoyed the company of colleagues and clients. Although a large proportion of her earnings went on child care, this had reduced recently, as her eldest child was now at school. She went on to say she was ‘sick to death’ with not being able to get back to the weight she had been before she had her children, and she badly wanted Kate to help her do this.

Kate felt alarmed when Jenny used phrases like ‘sick to death’, and she explained to Jenny that whatever she said was confidential between them but that if she considered Jenny’s health to be at risk, she would want Jenny’s agreement that she could talk to her doctor about these concerns. Jenny said this was all right with her.

How would you establish this boundary, if you felt you could be working beyond your limits? Take time to reflect here before reading on.

The middle stage

Kate invites Jenny to tell her about her eating patterns.

Jenny starts to tell Kate about a meal she had the previous weekend with friends from work to celebrate a birthday. Her voice is low; she speaks quickly, with her gaze fixed on the wall behind Kate.

‘I’d been really looking forward to going out – I hardly ever have the chance these days. All day I’d been telling myself I would only have a main course and a coffee, but I knew I’d blown it when everyone started ordering desserts. I ordered the chocolate fudge cake – I really love it – how could I resist? Afterwards, I began to feel stuffed to bursting point, and I knew I shouldn’t have eaten it all. Before we all left the restaurant, I went to the loo and caught sight of myself in the mirror. I looked awful! I felt awful! I wanted to die, I felt so bad. One of my friends came to get me – I’d been there so long – and then we went home. I’m not sure how I got there, but the next thing I remember was waking up and vowing to myself I wouldn’t eat another thing ever again! So, you see, the whole evening was a disaster. I reckon I’m a pretty hopeless case.’ Jenny gives a hollow laugh.

Kate notices the tears in Jenny’s eyes and is aware of feeling increasingly anxious herself as she listens. Is Jenny saying she wants to commit suicide? Kate wonders if Jenny has a binge-eating disorder; also, how much, if any, alcohol Jenny drank that evening, whether she has had similar experiences in the past and whether she made herself vomit or took laxatives while alone in the toilet. She wonders how best to respond.

How do you think you would respond in this situation? Take time to reflect here before reading on.

The interview continues...

Kate focuses on staying calm. As Jenny is so emotional, and as she seems to have a pattern of disordered eating, Kate decides the most important thing is to use her counselling skills and to focus on building trust. She is aware that she feels a little overwhelmed by the multitude of issues that Jenny has presented, and also by her unstable emotional state. She decides to focus on the risk of suicide, which seems to be the most urgent issue. Keeping her eyes on Jenny’s face, she speaks slowly, her voice at normal volume and her tone gentle. She reflects both the content and feelings expressed by Jenny, by summarising what she has understood:

‘I can see you feel very upset and I hear you say you think the whole evening was a disaster. You seem very ashamed of eating a dessert – so ashamed, you even wished you didn’t exist anymore.’ She pauses, noticing Jenny is looking down at the floor. When Jenny doesn’t say anything, Kate continues, ‘I’m thinking it took a lot of courage for you to tell me what happened’.

Jenny looks up with a surprised expression. ‘Courage? I’ve never thought of myself as having courage. It’s more that I’m desperate.’ She sighs. After a few moments, she continues, ‘I can talk to you – you don’t tell me what I should and shouldn’t do all the time like some people’.

Kate registers this remark as an indication that Jenny is building trust in her relationship with Kate. She notes also Jenny’s acknowledgement that she is feeling desperate. Is this an indication of her motivation to change, or another indication of suicidal thoughts? If it is the latter, Kate will need to refer her for an assessment of her mental health.

How do you think you’d feel in Kate’s situation? What would be your next step? Take time to reflect here before reading on.

The interview continues...

Kate needs to know more to assess Jenny’s degree of risk, and so says to Jenny, ‘I’m glad you feel you can confide in me, and I want to help you. When you say that after the meal last weekend you felt desperate and you wished you could die, I’m wondering whether this is the first time you’ve felt so bad or whether you often think about suicide?’

Jenny replies, ‘Yes, quite often. I wouldn’t actually do anything, though, ’cos of the children. My doctor thinks it’s because I’m depressed, and I suppose he’s right. I feel worse about myself when I can’t control my eating. I guess that’s why he sent me to see you.’

Kate focuses on reflective responding, and says, ‘So, your doctor knows you’ve been having suicidal thoughts, which seem to be more frequent when you don’t feel able to control what you are eating.’ Kate wants to clarify what Jenny perceives as her goal. ‘You want to be able to control what you eat?’

Jenny nods. Kate continues, ‘Is this a problem for you all the time, or only on particular occasions like last weekend, when you eat out with others?’

Jenny replies, ‘Oh, I guess it’s pretty much in my mind all the time.’

Jenny continues to tell Kate how low she has felt since her second child was born 2 years ago, how tired she is all the time, how isolated she feels and how worried she is that she is not being a good mother. The more Kate hears of Jenny’s life, the more she realises that Jenny’s difficulties are compounded by her circumstances. She also realises they have 10 minutes left. She decides to focus on making a contract with Jenny.

How can she do this? Take time to reflect here before reading on.

The interview continues...

Kate first summarises their interview so far:

‘Jenny, I’m aware we have 10 minutes left today and I’d like first to recap on what we’ve talked about. From what you tell me, you have been finding life quite a struggle for a while now. You’ve been trying to lose some weight, but then when you eat something you’ve told yourself you shouldn’t, you feel so bad about yourself that you eat even more and then end up feeling even worse.’

Kate pauses and, seeing Jenny nod, continues: ‘I’m wondering how best to help you stabilise your eating pattern, which will help you to stop binging. We could arrange another meeting to talk more about how you could adjust what you eat, and after this we could see how you could lose a little weight on a balanced diet. Maybe I could help you think how you could say no, for example to the dessert in the restaurant, so that another time you have some new ways of coping...if you think that would help?’

Jenny nods and Kate continues: ‘I think we will need to meet regularly at first, perhaps once a fortnight – how would that be with you?’

For the first time, Kate sees a smile flit across Jenny’s face. She says to Kate, ‘I’d like that.’

Kate wonders if Jenny would be willing to consider other sources of help for her binge-eating behaviour, depression, isolation and low self-worth.

How can she address this? . Take time to reflect here before reading on.

The interview continues...

Kate thinks Jenny would benefit from some psychological/emotional support in parallel with dietetic appointments, and that, with Jenny’s permission, she could request this referral via Jenny’s GP.

Maintaining eye contact, Kate says, ‘I’m also wondering what you think about talking to someone who is specialised to support you with the depression and binging problem, as well as myself? How would you feel about that?’

‘That sounds a bit serious, but if you think it would help...?’

‘Yes, I do. If you agree, I can discuss it with your GP and we’ll see what we can arrange’.

(The middle stage ends here, as they move into the ending stage of their interview, which is spent sorting out future appointments and giving Jenny an opportunity to say how she has found the interview and to ask Kate any questions).

Further study and points for discussion

The questions below are to help you reflect on the middle stage of the interview. Relevant information can be found in Chapters 3, 4, 5, 7, 14, 15 and 16 of Counselling Skills for Dietitians.

• What tasks has Kate fulfilled in this middle stage of the interview?
• If you were in Kate’s place, how would you conduct these tasks?
• How does Kate demonstrate each of the core conditions of empathy, acceptance and genuineness?
• What effect does this have on her relationship with Jenny?
• How aware is Kate of her own feelings? How does she use this awareness?
• After the interview, Kate feels somewhat drained. What actions might she need to take?

Afterwards, Kate reflects on her interview with Jenny

Kate feels concerned about Jenny and uncertain about how to proceed next time. She makes the following notes for her own personal use. She will destroy these once she has finished getting her thoughts down on paper. She writes:

What do I know of Jenny?	Female, 33 years
What is Jenny’s health like?	Binges, may self-induce vomiting or use laxatives. Slightly overweight since first pregnancy, said she often has suicidal thoughts but would not act upon them. Said her GP knows about this.
What did she tell me about her life?	Hairdresser - enjoys job and company. (Nothing about partner/husband/father (or fathers) of her children/other members of family.)
What did she tell me about her diet?	Perhaps need to take a diet history next time, or ask her to keep food diary to find out more about her patterns of eating and nature of binges.
Who provides support?	Talked about friends.
Presenting issues?	Said she was ‘desperate’ to control her eating. Thinks her problem is because she hasn’t got back to her pre-pregnancy weight. GP told her she’s depressed. Is food her way of coping with this?
What does Jenny want from me?	To help her lose wt? But she thinks she should lose twice the amount I think she should! Will need to discuss realistic target weight and rate of weight loss. Need to re-emphasise the importance of first stabilising her eating pattern.
Was she underweight before pregnancy?	Need to explore history of eating distress.
Does she want me to help her explore this?	Now I’m feeling anxious and out of my depth!
What can I offer Jenny?	Support with establishing regular meals, portion sizes and making healthy choices, learning to say no so can feel more in control.
What was agreed?	Fortnightly appointments and to speak to GP about psychologist referral.
Focus for next time?	Continue to build relationship. Possibly use some CBT [cognitive behavioural therapy] to help her think differently about her reactions to food. Contact GP re psychology referral.
Am I out of my depth?	Will discuss with S [eating disorder dietitian in department] and in supervision.

Many dietitians find it helpful to role play situations such as the interview between Kate and Jenny with a colleague. In doing this, it is valuable to enact both roles, so that you get an experience of being both the dietitian and the patient. Allow time to discuss with your colleague and to debrief before switching roles, and again at the end of the exercise.

As raised in this interview, many dietitians may feel uncertain about the boundary between dietetic counselling and psychological intervention. It is essential for the dietitian to review and assess their ability, skills and competence so they can recognise when they are working beyond their limits (Chapters 4 and 16).

You are recommended to use the book...

To read about building a helping relationship (Chapter 1).

To read about the interview framework (Chapter 5).

To read about the different types of response and intervention (Chapter 7, 8 and 9).

To read about working with eating distress (Chapter 14).

To read about working within one’s limits (Chapter 15).