Chris Clark doesn’t have to go very far to see the intersection between counseling and nutrition. He can simply look across the dinner table where his wife, Kristine Clark, a registered dietician and clinical exercise physiologist, sits with their three children in Rock Springs, Wyo. Clark, a licensed professional counselor and American Counseling Association member, and his wife have rich dinner conversations that go beyond the typical headlines about how nutrition and fitness affect mental health.

“I do get a vicarious [nutrition] education through my wife,” acknowledges Clark, who also spent three years at Duke Integrative Medicine, first as a counseling intern and then as a research assistant. During that time, he worked on studies that investigated mindfulness as a treatment for binge eating disorder and for maintaining long-term weight loss. He also worked in fitness and aquatics at the renowned Duke Diet and Fitness Center.

“I was immersed in everything related to health care and wellness,” he says. “As a counselor sitting in on the health psychology side, I really got to see the benefits of a balanced approach to wellness.”

Not all counselors have the advantage of being married to a registered dietician who can provide convenient at-home case consultation, of course. But with the widespread focus on a holistic approach to health, many in the counseling profession are seeking to deepen their understanding of how improvements to diet and fitness can also boost mental health. When counselors strive to emphasize the physiological along with the psychological, however, there are ethical and legal issues to consider. Outside of adding another graduate degree to their résumés, teaming up with the appropriate experts is the approach these counselors recommend.

Connecting the dots

“I personally ask all clients about their diet” regardless of the presenting problem, says Clark, who now teaches at Western Wyoming Community College and has a part-time private practice. “Processed foods, high fat [or] high-sugar goods, artificial colors and flavors, all can influence mental and physical health greatly. In my experience, food is often a source of self-medication or a crutch to escape emotional or psychological pain. Additionally, alcohol and caffeine use are major contributors to depressive symptoms, including sleep disruption. I like to [talk about diet as a part of the counseling process] as a way to give the client greater control over the way they feel.”

Even after being referred to a registered dietician, clients typically continue seeing their counselors to work through the psychological aspects of the eating issue, Clark says. The dietician will work specifically on eating and food prescriptions, using a solid behavioral plan that the counselor can support by helping the client to become more aware of thought patterns, he explains. Ongoing communication between the counselor and the dietician is important but must be entered into only with the client’s consent. “Couching this communication [as part of] ‘wraparound’ care helps the client feel more comfortable if they are hesitant,” notes Clark, who adds that most clients seem to appreciate this approach.

Counselors may find that working a case alongside a registered dietician can lead to better overall outcomes. Clark offers the example of one counseling client who was struggling with his weight due to alcohol consumption, which was exacerbated by his need to wine and dine his business clients. Responding in part to a dietician’s interventions of using mindfulness and recording caloric intake, the client concluded that, for personal and business reasons, one drink per meal was more appropriate. “This was enough of a change that he began to see more consistent results on the scale, and the client reported feeling more grounded and in control during business meeting meals,” Clark recalls. “Even though I could have brought up these concerns and had certainly discussed them, [having them come] from a dietician had greater impact.”

Heather Smith’s enthusiasm for raising awareness of nutrition’s impact on mental health led her toward a career in counseling several years ago. “At the micro level, counselors should pay attention because nutrition affects how we feel, think and behave every day. All of our body’s processes are fueled by the nutrition we take in. That means that none of the emotional, spiritual, mental, chemical, biological [or] physiological processes can function adequately without the nutrients required to sustain them,” says Smith, a member of ACA. “At the macro level, counselors need to know that we live in a toxic food environment. In most places in the U.S., choosing healthy food is difficult, [while] choosing nutrient-poor food is easy and cheap. Encouraging clients with health-promoting nutrition messages helps counter profit-seeking messages that bombard us daily.”

Today, Smith is an assistant professor in the human development counseling program at Vanderbilt University in Nashville, but she started out as a registered dietician with aspirations of pursuing a master’s degree in public health. “My work as a dietitian helped me to realize that my clients confided in me a great deal,” she says. “I learned that when my client was manic, I needed to change my approach. I realized what a difference client-centered listening made as I witnessed depression in the eyes of my client with diabetes. I took on the job of helping clients communicate better with other medical providers and soon found that I yearned to be a better advocate for treating the whole person.” Smith was drawn to the counseling profession’s focus on wellness and human development, and went on to earn her master’s degree in community counseling and her doctorate in counselor education.

Smith says her varied experience has highlighted for her the ways that nutrition and mental health information have been fragmented via the health care delivery system. “Individuals are often responsible for putting the pieces of information together in order to make meaning and decisions about their own care,” she says. Although counselors benefit from possessing an understanding of biology, chemistry and biochemistry, that is not a prerequisite for simply helping clients learn how to become better communicators with their physical health care providers, Smith points out. “I find that the amount of time patients spend in direct contact with their physical care providers isn’t enough time for them to think about what is most important to communicate and to communicate it effectively,” she says. “This is a gap that counselors have tremendous capacity to fill.”

Personal examples

Kathie Erwin is a licensed mental health counselor and ACA member in Largo, Fla., with firsthand knowledge of this gap. Resulting from her own journey to lose weight and avoid serious medical problems, Erwin decided to augment her counseling career by becoming a certified health coach. Today Erwin is an assistant professor of clinical mental health in the graduate program at Regent University.

“It is physically and emotionally liberating to be healthy,” Erwin says, adding that counselors can help clients to see the connections that can lead to overall improvement. “A person who is depressed may either not eat adequately or eat only sugar-based items. In both cases, the brain is not getting adequate protein or useful fats to operate properly. The ‘sugar highs’ lead to blood sugar crashes, which further dampen mood. With children exhibiting attention-oriented symptoms, I refer parents to a physician for possible allergy testing. Some food allergies can adversely impact attention. If the food allergy is properly managed or treated and the attention/behavior improves, that is a win-win.”

Erwin recalls the case of one of her health coaching clients, Lynn Ellyn Robinson, who was under stress, overweight and suffering from gout. Erwin’s approach was to teach Robinson healthy habits, including a specific diet regimen. “She progressively lost weight, and her gout symptoms reduced,” Erwin says. “She also began to feel better about herself and her mood improved. She has maintained that loss for over four years. … Instead of [seeing her use] a walker bent over with gout pain, you will see her wearing stylish high heels.”

Robinson, who has a master’s degree in counseling, went on to become a certified health coach in the Tampa/St. Petersburg, Fla., area. She sees a direct correlation between learning a healthy lifestyle and achieving better mental health. “Once I began my own weight-loss regimen … I noticed a distinct lifting of my mental/emotional mood and an improved ability to deal with life’s challenges — a state which is now a way of life. Making the ‘habits of health’ a part of daily life has led to ongoing good health, which contributes to an overall positive outlook.”

Nontraditional partnerships

For those wishing to offer more meaningful nutritional consultation to their counseling clients but who are not in the market to add health coaching or other credentials, both Smith and Clark recommend seeking out registered dieticians for case consultation and partnership. The typical partnership would have the counselor focusing on behaviors, with the registered dietician focusing on food choice and portion control.

“Undoubtedly, counselors will work with clients who have diabetes, cancer, injuries, disabilities, respiratory illnesses, diseases of the digestive tract, eating disorders, surgeries [and] joint replacement,” Smith says. “Your client’s nutritional status affects all domains of health.” Individuals who have earned the registered dietician credential have fulfilled specific prerequisites and maintain continuing education requirements, she says. Smith adds that although some registered dieticians may call themselves nutritionists, not all nutritionists are registered dieticians.

Natasha Watkinson initially took the partnership concept to heart — and to a different level, launching her counseling career with a chef as her business partner. Their private practice, Holistic Home & Health LLC, in Asheville, N.C., followed an integrative model that incorporated individual and family mental health counseling with meal services, pantry consultation and home organization. Their clients could take part in some or all of the offerings, which included complete meal delivery and education about food preparation. Watkinson and the practice’s chef also pursued consultations with nutritionists and registered dieticians.

“Access to professionals who share a similar philosophy to wellness as yours is most important,” says Watkinson, a member of ACA. “Consulting, referrals [and] collaboration/integration will grow from there.”

In North Carolina, Wilkinson said her role was more that of a mental health consultant to Holistic Health and Home’s food clients and chef.  She recently decided to return to South Florida, where she says she will place much more focus on mental health counseling and start clients’ change process from that perspective. She still firmly believes in a holistic model to client care and well-being, however, and says she plans to use a nutritionist as a consultant to her and to her clients.

“Food is emotional and nutritious,” Watkinson says. “It gives us a feeling of control over ourselves and, yet, can also indicate a loss of control over our lives. Nutrition is becoming more accepted in Western culture as a point of imbalance [that] can significantly affect mood. The risk for counselors is to view a client’s affect or mood as only situational or chemical and not even consider a dietary or nutritional cause, which can influence many symptoms clients often report as fatigue, depression, irritability, lack of focus, etc.”

“We found [at Holistic Home & Health] that the people who were receiving food through our program were interested in making changes in the way they were living their lives,” she says.

“Food is one area, but there are so many others. Diet and well-being are enmeshed. I was working with people who reported symptoms of stress, fatigue [and] feeling a ‘lack of control’ in their lives. … My goal was to address these concerns from a holistic approach.”

Tools and techniques

Increasing understanding of a counseling client’s nutritional health can be as simple as asking a few key questions. “Counselors who inquire about or mention health-promoting behaviors can expect clients to share more about their overall health functioning,” Smith notes. “Something as simple as asking clients how they are preventing colds and flu can lead to prompting a client to list how many vegetables or fruits she’s had in the past two days. Such efforts have resulted in clients later expressing appreciation for my caring. I suspect what they mean is that I care enough to consider their physical experiences as well as their emotional ones.”

Watkinson says the client intake process is a simple and effective place to include deeper inquiries about physical health and wellness. “I think attitude toward food and body image, an inventory of a typical day’s menu … and the client’s definition of wellness should all be part of a general intake questionnaire, as well as our ongoing assessment,” she says.

Clark emphasizes that counselors must be thoughtful about the methods they use to incorporate nutritional dialogue into their work. “Be aware of the judgment that comes with food and diet,” he says. “[The client] might be feeling overwhelmed and judged to start with. … [I recommend] just being matter of fact about it, starting with a very basic approach: ‘Most people don’t realize that the basics of weight management are calories in and calories out. Let’s look at how this is working for you.’”

Clark completes a comprehensive intake with all clients. “I tell them I’m going to ask about their lifestyle, including sleep, eating behaviors, nutrition, exercise habits, stress levels, coping mechanisms, etc.,” he says. “This takes all judgment out, and you get a lot of valuable information about their life situation.” Providing all of this detail also helps clients to see the bigger picture and encourages them to make their own decisions regarding where they want to start making lifestyle changes, Clark says. “For instance, they may not be ready to talk about changing their food choices, but they may be OK with starting an exercise program or improving their sleep hygiene. But they will be more aware of what they are eating and, sooner or later, they will be willing to address their eating patterns as part of their own treatment.”

According to Clark, journaling, a regular part of most counselors’ tool kits, offers a no-pressure way to get clients thinking about nutrition. “Ask clients to write down what they eat, taking note of their physical, psychological and emotional state before and after they eat,” Clark says. “This will give them an idea about how their physical and psychological states may be influencing their food choices. Additionally, they may be able to start drawing correlations to how what they eat and how much they eat influence their psychological and emotional states.”

Smith suggests using the regular counseling process to get a better sense of how clients make meaning out of their health. For example, consider how they problem solve around issues related to physical health, and be curious about their perspective. “Think about their ability to define a ‘major medical condition’ and how they connect that to sugar, high blood pressure or insomnia,” Smith says. “Consider asking about the last time they had a physical exam. Do they experience pain on a regular basis? What do they do for exercise? How do they get fresh air? How many fruits and vegetables do they typically eat?”

One ethical caveat is that counselors must be aware of the boundaries of their competence when it comes to adding nutrition-focused questions and interventions. “Just like [with] counseling, nutrition science and practice is a discipline that requires training and years to become proficient,” Smith stresses.

“I’ve experienced many well-intentioned people [who] ‘help’ individuals with their nutrition or mental health concerns,” she says. “One way to think about the boundaries is to think about information that is generally available to the public from reliable sources, like government publications [from the Food and Drug Administration or the U.S. Department of Agriculture]. Study their recommendations and the populations for whom the recommendations are made. Counselors can weave these recommendations into their work with clients.” When it is time to refer the client to a nutrition professional, counselors must recommend licensed practitioners, Smith emphasizes.

Clark echoes that advice, adding that counselors should be cautious about making any sort of dietary prescription absent the input of a doctor or registered dietician. He points out that some people get bad advice — such as cutting out entire food groups or following fad diets — from personal trainers and other fitness enthusiasts. “We need to be sure not to overstep our boundaries [as counselors] and stick to the general guidelines of what we know is healthy,” he says.

Speaking from her perspective as a former client, a certified health coach and someone who holds a degree in counseling, Robinson advises counselors to approach clients holistically, asking health-related questions from the early stages of therapy and checking in about their food, sleep and exercise habits at every session. Counselors should also make a point of doing their own homework, she says, staying informed about what it means to maintain a healthy lifestyle.

Further, Robinson suggests that counselors set a healthy example themselves. “Learn by doing. The days of ‘do as I say, not as I do’ are long gone. The therapists from whom I have learned the most have been those who are [engaged in ongoing] work on themselves and their own lifestyles,” she says. “They led by example, not lip service.”

Contributing writer Stacy Notaras Murphy is a licensed professional counselor and certified Imago relationship therapist practicing in Washington, D.C. To contact her, visit stacymurphyLPC.com.

Letters to the editor: ct@counseling.org