Reading Reflections: Motivational Interviewing in Healthcare

I had an interesting experience with Urgent Care recently. After the very last snowfall of the season, in early April, I had fallen on the slushy front steps when I went outside to sprinkle some salt so no one would fall and hurt themselves. I landed smack on my butt, and did something impressive to my tail-bone.

I couldn’t walk normally, I couldn’t go up and down stairs normally, I couldn’t sit down or stand up normally. It hurt. It really, really hurt, and it didn’t go away after a few days, and it didn’t seem to be getting any better.

After one week of hobbling around and levering myself up from chairs, I broke down and went to Urgent Care for an x-ray. I didn’t really think it was broken, and I knew that sometimes the fractures don’t even show up in the x-rays, but I thought I should get a professional opinion anyway.

It was a somewhat ridiculous experience, and I couldn’t’ quite figure out why until I started reading Motivational Interviewing in Healthcare (by Rollick, Miller, and Butler) for school.

Motivational Interviewing (MI) focuses on practitioner’s conversational skills with patients and clients to enable behavioral change. The position of the authors is very clearly that simply telling patients/clients what to do from a position of authority is an ineffective way to deliver healthcare and often highly counterproductive. Rollick, Miller, and Butler suggest that instead of directing, providers spend a little extra time (sometimes only adding a minute or two to the conversation) developing a relationship with the patient and use active listening to fully understand where a patient is emotionally as well as how they understand their situation.

Working from within that relationship, in which the patient is treated respectfully, as an individual, the provider can gently inform and lead the patient toward the changes that they need to make. By involving the patient and obtaining their cooperation in the process, the provider will find they understand the patient’s situation much better, and the patient is far more likely to follow through with the necessary change.

The problem with my experience at Urgent Care was that, despite being the only actual patient in the building, everyone was rushing around as if the queue was full of people. Conversations were as brief as possible. The doctor rushed through his examination and lectured me, delivering his words in rapid-fire. By the time I was out the door, I was dazed and annoyed. I couldn’t quite remember all the instructions he had given me. He hadn’t really listened to my description of my injury and my experiences; in fact, some of his questions were sufficiently closed that they limited the information I had the opportunity to give him.

It wasn’t a serious injury; the bone wasn’t broken. I just needed to rest it and not aggravate it. But I can see the potential for problems with such a poor interaction between provider and patient. On the other hand, MI seems to open the doors for a much more meaningful conversation, enabling a much fuller interaction between provider and patient.

Nutritional Therapy Training and Daily Posts

I’ve been establishing the habit of daily posting to work on my (nonfiction) writing. It has been so long since I was in school, when I could crank out a paper without thinking about it, that I feel like my ability to write well on a topic has gotten rusty. The only solution to feeling incompetent in something, as I tell my kids, is to practice. So I’m practicing, and practicing, and practicing, by making sure I have something to post every single day.

How can I have something new to say on a daily basis? Well, the fact that I just registered for nutrition therapy training will probably help out with that considerably. Fifteen modules, eight or nine months, a whole bunch of books to read: plenty to write about. I plan on reflecting on my coursework here, and to make sense of it and test my understanding. Trying to explain something to another person, or to write clearly about it, highlights areas to study more.

I hope that writing about what I’m studying will help me be able to explain things more clearly to my clients, once I get through the program and start consulting with people on nutrition. I’m a slow thinking—I prefer to be able to think about what I say before I say it—and I think that working through ideas here will help me with teaching and answering questions and objections later.

Food Diary for Kids? A First Attempt

We need to start a food diary for my oldest daughter, to be able to track her food and correlate it to symptoms. It needs to be something she can do herself with minimal work from me. I’m not quite sure how to do it. Having an app would be entirely unhelpful, because they all seem to be calorie focused, which is the last thing I want to introduce to a twelve-year-old girl. Writing things in a notebook might work, although I suspect it would be too onerous for her.

I’m inclined to dig out her camera (it’s here somewhere…), keep it in the kitchen, and have her take a picture of what she eats. Or maybe use one of the old phones we have around. That way it might be a little easier to work with. Maybe have her make comments in Scritch or something? She likes photography, so this might be a good option.
It comes down to experimentation: we’ll try taking photos on an old phone and see how it goes. In a few days, we can evaluate. Then we can tweak it as necessary.

Status Addendum

Another effect of the change in diet is that my oldest daughter’s appetite has increased. This is probably another multi-faceted problem, but probably includes being easily distracted from eating, forgetting to eat, quiet pickiness (if she doesn’t like something she doesn’t make a fuss but just doesn’t eat it), lack of hunger, and being unable to distinguish between hunger and not feeling well.

She has always enjoyed a big chunk of meat, whether that’s steak or a piece of chicken. But she’s also stepped up the amount of breakfast she will eat. Previously, she was eat a fairly light breakfast, but now she will eat five egg yolks in butter (she usually doesn’t care to eat the whites), or drink about a cup and a half of breakfast smoothie (which, in our house, is quite low in sugar and high in fat). She also usually has a bedtime snack, unless dinner was quite late, and has taken to eating quite a large amount of almond butter.

That she has developed a taste for fat is a good sign, because fat, along with protein, is what our body is made of. In particular, it is helpful both for brain health and development as well as for the digestive system. It’s these areas that are giving her the most problems, so are most in need of healing.

A Status Update: Improvements in acid reflux, blood pressure, anxiety, weight, and sugar cravings

A status update: Improvements in acid reflux, blood pressure, anxiety, weight, and sugar cravings.

We’ve been following the GAPS diet, with a handful of off-plan meals, for about 48 days. I started us by doing the Intro diet, but after a couple of weeks decided it was too much for us, even though we were transitioning from a mostly paleo diet. I wanted to get a better, more consistent base down before I figured out how to incorporate probiotic foods, and more broth and soups. Eliminating even paleo and gluten-free starches was more of an uphill battle than I had expected.

The first change, and the most impressive because it was totally unexpected, is that my youngest daughter stopped having acid reflux within the first week or two. She has always had a powerful gag reflex, and would talk about “throwing up a little in her throat” from time to time, but it never seemed like an issue to investigate, and it didn’t bother her, so I didn’t pursue it. In fact, I didn’t really realize that she was having acid reflux until she told me that it stopped (reluctantly: “Mom, I’ll probably regret telling you this, but since we started this diet I haven’t been throwing up a little in my throat. There, I told you.” Knowing the potential for long term damage to the esophagus, I was a little shocked when I figured it out, and relieved.

A second change, this time much more expected, was that my husband was able to stop taking his blood pressure medication. In truth, he only had borderline-high blood pressure, but he was took a pill every morning, as instructed by his doctor, regardless. Within the first couple weeks, he was suffering the effects of low blood pressure, and had to step down to first taking a half a pill, then dropping them altogether. Although since his work is incredibly stressful right now, he occasionally takes one when he feels he needs to. He eats what we eat when he is at home, although at work he makes his own choices. Overall he tries to eat less wheat, less grain, less sugar, and when he does choose to eat things like pizza, as he did last week, he usually finds it reinforces his better eating decisions. He tends to make changes more slowly but more permanently than I do. He also prefers to make his own decisions, but responds well to information and education (when given very sparingly and with a light hand).

I found that I lost between five and ten pounds (I don’t keep close tabs, since checking my weight is disruptive for my well-being), and reduced my taste for sugar. If it’s available I will still eat it obsessively and without stopping: it’s still a food with no brakes for me. But when I do, I’m much more aware of how terribly sweet it is. I taste sugar more in processed foods as well, or at least the few I’ve eaten. Yesterday we had cookies after a music recital, and since my youngest made meringues to take with us, we had those in the house as well (and we had fewer to take than we would have, since I kept having ‘just this one’.) It was a quiet relief to sit down to chicken and Cesar salad for dinner last night, and not be eating sugar. The kids also appreciated having a real meal after all the sugar.

Unfortunately for my oldest, the cookies followed on the heels of the dinner we had at our favorite Mexican restaurant the night before. We avoided the beans and rice that are usually served on the side and we didn’t get horchata (a highly-sweetened rice drink), but we did eat freely from the basket of chips. We also had tortilla-based meals—my oldest had nachos supreme. By that night, her anxiety and overwhelm had returned.

She was the reason we were following GAPS: always a bit quirky and definitely ADD/ADHD, she began having increasing difficulty with anxiety and being easily overwhelmed within the last year. It became crippling, to the point where she could not make progress in her schoolwork because she simply crumpled under the stress of trying to learn something new. We have learned that she tends to be sensitive to diet, and realized that we had slid quite far from paleo: a change was required.

Within a few weeks of starting the GAPS diet her anxiety decreased, and for the last two or three weeks, she has been able to progress normally through her schoolwork. She remains highly sensitive to deviations in her diet, though, and eating off-plan shows up in her mood. Our Mexican dinner was a good trial, even if the results were difficult for her, because it illustrated that even just eating corn is enough to throw her out of whack.

Previously, I had treated (processed) corn as a relatively safe food, because it is gluten-free and I had never seen a good argument about its effects. One book, after spending pages and pages discussing the harmful effects of wheat and gluten, said corn probably had similar effects and should be avoided. I clearly need to do more research to figure this out. It could be that just the high carbohydrate content is stimulating the more opportunistic gut bacteria, or it could be something specific within the corn. I don’t know right now.

Overall, though, the GAPS diet has had a positive impact on all of our health, and for my oldest, has been life-changing. We’re still incorporating all aspects of it, but this is obviously the direction that we need to be going.

Very Filling Breakfast Smoothie

My oldest daughter is not a big eater, and it can be difficult to find foods that she is enthusiastic to eat. Breakfast has become a meal that she will reliably eat (it helps that she’s allowed to read during breakfast, so she’s happy to sit for as long as possible), and our transition to exclusively whole foods breakfasts has been relatively easy. The girls still look back fondly at breakfast cereals and oatmeal; what they don’t remember is that cereal wasn’t filling for them at all, and they had to have a snack about an hour after they had finished eating.

These days, breakfast is either a berry smoothie or eggs. The smoothie is relatively easy to make and is quite filling for them. Despite the fact that it’s a fruit smoothie, focusing on berries means that this recipe actually contains very little sugar, leaning more heavily on protein and fat.
Berry Breakfast Smoothie
Serves 2

1/2 cup melted coconut oil (approximately—I don’t worry too much about exact amounts since I’m digging it out of a bucket)
4 eggs (we use our own eggs from our own hens, use your own discretion on adding raw eggs)
2 cups frozen berries, defrosted slightly

Add ingredients to blender in order and blend until the oil and eggs are well incorporated and the fruit is not longer chunky.

Small Steps, Big Changes

It is tempting to sweep everything aside and make huge changes with what we eat. Throw out everything at once and bring in all new foods, all new ways of cooking, all new menus. For some people that might work well. In my imagination, it certainly is the best way to do things: if what we are doing now is mediocre, adopt the best practices right away. Why wouldn’t that be for the best?

The problem with giant steps is that there are so many habits and behaviors ingrained around food that changing all of them, in one sweep, has been too overwhelming and disorienting for us in the past. I’m sure there are plenty of people who adapt well to massive changes like that, but I’m not one of them, nor is the rest of my family.

We’ve established two days of the week with set dinner menus: Sunday is make-your-own sushi (my daughters’ favorite) and Monday is make-your-own nachos (my husband’s favorite). The routine is helpful for everyone involved, and they are comforted to know that, whatever else we have to eat during the week, there will be at least two meals that they like.

It took a while to figure out how to adapt these meals to grain-free, since both have grains as a centerpiece. I figured that there would be a huge outcry and protest. I hesitated, reluctant to rock the boat. Perhaps it would be better to toss out the familiar meals and replace them with something new instead? Something without the conventional, grain-based anchors?

I tried it: I introduced all-new recipes for Sunday and Monday. I tossed Sushi Sunday and Macho Nacho Monday out the door. We ate paleo on those days instead.

It was, if not a disaster, at least not well-received. They wanted their familiar meals back.

So we went back, but I made sticky cauliflower sushi rice, instead of regular rice. I held my breath, waiting to see if it would be accepted.

It wasn’t.

But the rest of the meal was. They ate their sushi with minimal complaints (although my oldest was a bit miffed that sushi means ‘rice’ and there wasn’t rice). They would rather have the familiar meal without the familiar but objectionable ingredients than have something else.

I moved on to Macho Nacho Monday, and took away the tortilla chips. There were very few complaints. Again, they would rather have the meal, even if it was slightly different, than not have it.

I’ve had to make further tweaks, especially to sushi night, in order to make up for the missing calories (increasing the amount of fish available, and encouraging everyone to use plenty of mashed avocado to help hold things together as well as provide bulk and calories). But everyone looks forward to the new and improved sushi and nacho nights, and eats with as much enthusiasm as before the changes.

Overall, it confirms what I’m finding to be true: it is better to retain as much of our traditional menu and adapt it to the new requirements, than to throw everything out and use completely new recipes. Some things are challenging, some things haven’t adapted so well, but having the core of our week remain almost the same has helped with the transition.

Instructions, Information, Inspiration?

A prominent writer on minimalism wrote a post several years ago describing what minimalism looks like and how to do it: single picture on your desk; toaster, coffee maker, and microwave on the kitchen counter. The post went on, but I stopped about the time I got the the kitchen counter. I closed the post and unsubscribed from the mailing list.

The post wasn’t really about minimalism, it was a checklist for that particular writer’s brand of minimalism. It was instructions about what you had to do in order to do minimalism right.

I don’t believe in the One True Way for anything. I don’t believe that what I do is going to be right for everyone else. I don’t even know if what I do is going to be right for anyone else. But I do know that it’s right for me, at least at this time. Or it is a step in the right direction. Or it is the experiment I want to do.

I write these posts NOT to tell people what to do, but to show what I do and why. As a person who is struggling to make nutritional decisions in a world where much of what we think we know about nutrition and health is just wrong, I spend a lot of time trying to learn about both nutrition and my family’s nutritional needs. There is no single source of information that gives me all the answers and tells me exactly what I need to do with no modification.

I write to give options, to show what I’m working on and how and why. It helps me considerably to find out what others are doing and, most importantly, how they came to do it. Why do they think that way, how did they reach that conclusion? What are they trying and how can I tweak that for my family?

Ultimately, we are each responsible only for our own selves. It doesn’t matter the situation: I have to make the best decision for me, based on the information I have available, and I have to be the one to live with the consequences. The same is true for everyone.

Don’t take anything I say to be instructions on what you should do. Take it as information about what I do, take it as offering options, as inspiration, as an introduction to a different way of thinking about things.

And then make your own decisions.

Cancel the Turkeys (Because of the Ducks)

I raise chickens, both for meat and for eggs. This year, I thought I’d add turkeys into the mix, in order to raise our own Thanksgiving turkey and to be able to have some to sell. I’ve raised them before, with varying degrees of success, and had planned to make some changes this year in the hopes they would do better. I also ordered chicks to both increase our egg-laying flock and give it some new blood. The meat birds are a specific breed, so those had to be ordered as well. My youngest daughter loves ducks, and had been arguing in favor of getting ducklings again, and I finally gave in, adding a meat breed and an egg breed to the same order as for our meat chickens.

Then the ducklings came. They were adorable. They are now almost three weeks old. They are still adorable, but I remember why I don’t raise many ducks: they are messy. They can drain a five-gallon waterer in less than a day, soaking the wooden floor of the coop. They are goofy and clumsy and knock things over if at all possible. They don’t quite trample the chicks that they are living with, but not for lack of enthusiasm. They are flighty and when one of them spooks, they all race around their enclosure in a panic. They are trouble. They can’t be in with the meat chicks any more, because they are too much for that coop (and too much for the chicks). They’ll have to be moved out to another space with a dirt floor where the flooding won’t cause structural damage, and their goofiness won’t endanger chicks that don’t have the sense to get out of their way.

Last night I got the confirmation phone call that the first of my two batches of egg chicks (with a dozen tiny bantams as well) will be arriving tomorrow. The turkeys are scheduled to arrive next week. The second batch of egg chicks will be arriving about three weeks after that.

Suddenly, my brilliant plans for all the poultry I’ll raise doesn’t look so brilliant. It looks overcrowded. Where am I going to put them all? I have three spaces for putting the babies, but with the addition of the ducklings, I have four groups with specific needs. I thought the ducklings would be fine with the chicks, but their needs are just too different. The turkeys are too delicate to be in with the ducklings, and the bantams are too delicate to be in with the turkeys.

I’ve overbooked myself, and my space.

Something has to go, but the logical thing to jettison, the impulsively-added ducklings, are already here, already committed to. So it will have to be the turkeys, since I can cancel those. No homegrown turkey this year, darn it.

It’s not a great solution, but it’s the only one I’ve got right now, and something I brought upon myself with not paying attention to the limits of my space. Next year, I’ll have to remember this, and remember my frustration with my own poor planning. Actually, the planning was fine. The planning was just what it should be. The problem was I ignored the plan in the excitement of ordering chicks. Whee, let’s get ducklings too! So I’ll remember that too.

Next year, I’ll stick with the plan, so I don’t have to cancel the turkeys (that I really wanted) to accommodate the ducks (that were just an impulsive, last-minute add-on).

It’s Just Rain

It is raining quite hard right now. Normally I would not be awake yet, but I’m up and working in the living room with our largest, oldest dog on her leash attached to my ankle. If I let her off the leash, she will go into our bedroom and pant in my husband’s face in an effort to get his attention, or she’ll go upstairs and wake the kids for their attention. Instead, I get up, give her a little sympathy and scratches (not enough, she thinks), and get some work done.

It started with her being a little anxious with the loudest thunder and fireworks. Then she slowly, over the course of several years, grew to fear all thunder. Even distant thunder that was quiet and clearly no where near us. And then just a heavy rain would set her off, thunder not required.

That’s the problem today: it’s raining hard, and she doesn’t like it. We’ve tried sedatives and anti-anxiety meds, we’ve tried various training techniques, but when she’s upset, nothing will calm her down. She pants, she paces, she paws at me. She crawls onto our bed—she’s not allowed on any furniture, normally—and tries to lay on top of my face. And if I’m not properly sympathetic, she makes the rounds to the rest of the family to find someone who is. In order to let everyone else sleep, I usually get up with her like I did today, and then try to go back to bed once she settles down.

It makes stormy weather, and even rain, a bit of an ordeal.

How often am I just like her? I let something get so out of hand inside my head that I am completely freaking out and unable to function normally. I would do anything to avoid what I’m afraid of, and try desperately to get rid of it. Except it isn’t really a problem, or only a small one, but certainly not the epic disaster that I’m making it out to be. Really, if I just took a minute to put things into perspective, I would realize that I have no reason to be so afraid.

In the time it took to write this, the rain slowed enough that the dog stopped panicking and laid down to sleep on my feet. I’m going to spend some time thinking about some of the things I’ve been fretting about, and lay them to rest as well.