part0014

Putting It All Together: Making Recommendations
for Success

Diet Essential: Integrate behavioral change strategies
with the principle of substitutions.

The concept of biochemical individuality describes how each individual has unique nutritional requirements specific to her or his genetic makeup based in biological, cultural, environmental, and familial heritage. The essential concepts and methods I presented throughout the preceding chapters describe and explain the ways our clients can improve their well-being and reduce medication use.

Identifying the best nutritional approach for our clients, combined with determining how to best support behavioral changes while we engage their strengths to overcome obstacles, is the essence of mental health nutrition.

One of the first goals of a program for your clients is to help them to make the connection between what they eat and how they feel in order to overcome the nutritional dissociation they experience. What clients choose to eat frequently reflects a complex interplay between personality, emotions, family history, culture, and beliefs; all of this is bidirectionally influenced by biochemistry—their first and second brains. NT levels affect food choices and behaviors; some people use tryptophan-rich foods, fats, or sugar to self-medicate. The microbiome also influences food choices, as bacteria demand their nourishment. The brain depends on fats to communicate and the carotenoids (from carrots) affect how fast the brain processes information. The capacity to even adhere to a nutritional plan depends in part on NT levels; low dopamine may make it more difficult for a client to adhere to a nutrient program (Kharrazian, 2013), suggesting that we start with these clients by enhancing dopamine, the “pleasure” NT.

There will also be special issues that arise based on the mental health challenges facing each individual. Restoration of high-quality foods and delivery of nutrients is central to recovery from the psychotic disorders, though often fraught with challenges because self-care and adherence to a therapeutic program is very challenging with this population. For example, there are several avenues of nutritional intervention which have been demonstrated to improve and treat the schizophrenias and psychotic disorders. Factors affecting medication adherence depend heavily on patient support and therapeutic alliance along with client insight and the attitudes about and side effects toward medication (Kikkert et al., 2006). This reinforces the need to enhance the connections between the team members, especially between client, therapist, and prescriber. A reduction of side effects may be achieved by reduction of medication and an increase of nutritional methods.

Given all these interactions and the exploration of assessment, food, and nutritional protocols, where do we begin?

Our goal is three-fold:

1. Combine the knowledge we have acquired and analyzed about the client and then apply strategies drawn from psychoeducation, cognitive-behavioral methods with strengths-based methods, motivational interviewing, and coaching.

2. Define an initial mental health nutrition plan that will benefit our clients.

3. Support our clients to engage in and adhere to an increasingly progressive program of self-care; including expanding options for improved diet and supplementation protocols.

To accomplish these goals, we help the client to do the following:

• Identify positive changes that are achievable.

• Incorporate positive behaviors and relinquish negative habits.

• Identify and eliminate addictive foods one at a time.

• Present food and behavior substitutions that are satisfying.

• Choose the option of alternatives to harmful pharmaceuticals.

• Support strengths and work with obstacles.

• Support self-compassion.

NUTRITIONAL CHANGE TAKES TIME

It is natural that we want change to be fast, and we are conditioned to expect this by the promise of fast-acting medications and advertisements. But fast-acting often brings side effects. I advise a client with a chronic illness that it takes time to become ill; the causes have been in place for a while, and it will take time to recover and taking time to recover is worthwhile. Long-term chronic problems often require a period of 1–5 years to resolve, and I advise my clients to expect incremental changes every 3–6 months. I also reinforce that the degree to which they adhere to their program is the degree and rate at which they will recover. This is also not to suggest that false hope is offered. Some people, especially with chronic PTSD, anxiety, TBI, and psychotic disorders may still experience significant symptoms at times, but with this approach we seek a reduction of suffering and overall improvement, not a “cure.”

I use the metaphor of the growth of a tree when I talk with clients about the time it takes for nutritional therapies to work. I may guide them through a visualization on this image; a tree grows slowly, but surely, digging roots into the earth for stability as it spreads its branches and leaves to the sky. The roots absorb water from below and the leaves from above. Nourishment comes from many directions. There are many roots and branches and leaves, and over time the tree becomes fuller and stronger. This slow but sure approach promises success so that when a wind blows the tree does not topple over easily but moves with the wind. This is the process of nature and mental health nutrition.

Change takes place by integrating positive activities (habits) first and then eliminating negative habits (activities). Practically, this means a step-by-step approach to identify one positive behavior that will change or replace a negative behavior and by employing the principle of substitutions outlined in this book.

I also focus on the specific actions that will improve well-being. Based on goals we have set together. I ask clients to pay attention and watch for specific changes and suggest how long it will take to observe a change.

I focus on specific changes to watch for, such as the following:

• Reducing caffeine leads to better sleep.

• Eating breakfast and better quality protein will improve energy and mood stability.

• Increasing anti-inflammatory foods will reduce pain.

• Increasing magnesium intake leads to less anxiety and improved sleep.

STARTING OUT

In Chapter 1 , I reviewed the spectrum of roles the mental health nutrition clinician might play, including (1) psychoeducation, (2) collaboration, and (3) autonomous practice. The clinician new to nutrition may begin by incorporating aspects of nutrition into treatment. Generally our clients have suffered for many years without knowing why. Psychoeducation provides explanations illustrating the links between nutritional and dietary patterns and mental health. Psychoeducation also includes information about how particular nutritional recommendations are essential to the empowerment process. I explain that B-complex vitamins are used for blood glucose regulation and mood. This can reinforce a better understanding of how a B vitamin every day is important. I will share an herbal tea in the waiting room at each appointment along with a handout of the recipe. The tea is presented with a description of the ingredients and what those ingredients are good for and how to prepare the drink.

As you develop experience and expertise working with a client, you will deepen and broaden a comprehensive plan. When a clinician is just beginning to incorporate nutrition, I suggest first setting aside some time during each appointment to discuss the client’s self-care behaviors, focusing on nutrition. This approach provides an opportunity to make recommendations and discuss any obstacles while still carrying out the psychotherapeutic process. Focusing on the information collected in the Food-Mood diary is a good place to begin this process, and this will lead to providing homework that incorporates the results and decisions arising from a discussion about the diary. Providing handouts and resources complements this process. Once this first phase is complete, the next stage involves a more complex analysis and the development of a written report containing dietary and nutritional supplementation protocols.

FIVE STAGES OF CHANGE MODEL

The stages of change model describes five points of readiness and provides a framework for understanding the change process. By identifying where a person is in the change cycle, interventions can be tailored to the individual’s “readiness” to progress in the recovery process. Interventions that do not match the person’s readiness are less likely to succeed and more likely to hurt rapport, create resistance, and impede change.

The stages of change model, which began in motivational interviewing to treat the addictions, has excellent application in nutritional counseling. Just as we strive to find a method or technique that is isomorphic to the client’s belief system, identifying the stage of change of the client promises greater success in aligning intervention and goals .

Providing a Written and Verbal Report

I write a comprehensive written report and analysis for each of my clients. I then allocate time to review it with them while they read along. I suggest recommendations in the report that are tailored to the client’s needs along with reference materials.

Based on your client’s readiness for change and the degree to which she is willing to make changes in her current nutritional patterns, you may choose to go step by step with small incremental changes, or your client may be ready to implement a comprehensive analysis that points the way to change that will be enacted over the next 6–12 months. Their stage will determine your approach. For example, you may decide to work with a client using the principle of incorporating one healthy behavior while eliminating one unhealthy choice.

Based on the stage of change and motivational interviewing methods I describe next, goals and steps can be divided into 1-, 3-, or 6-month phases that are flexible. This approach allows the client to act immediately and also keep in mind future goals. Following the initial review of the plan, the client will need time to digest the report and ask questions, and it is very likely that when the client returns to the next appointment, more questions and concerns will arise. Subsequent sessions can be designed to continue the conduct of therapy with part of each session assigned to discuss progress, obstacles, and “check in” about the client’s progress. Our approach in this work will be colored by our own theoretical orientation, but we must maintain therapeutic rapport and trust regardless of our methods.

During the assessment process you have compiled and integrated information about the client and her narrative and the kinds of strengths and challenges she brings to the change process. At this stage, you will clarify those strengths and identify obstacles and prioritize goals with her. Often too much focus is placed on what clients cannot eat rather than what they can. This can be an emotional trigger. Focus on what they can have, and include foods they enjoy eating. You may discover that your client will benefit from a variety of pills or capsules, but you may also discover that she has difficulty swallowing them. You may want to suggest liquid oils or powdered nutrients. A client may discuss financial obstacles in buying nutrients; part of your emphasis may be to identify how to ensure those nutrients are available through whole food preparation and selected supplement purchases. An example of this approach is exploring whether it might be better to obtain probiotic bacteria by preparing sauerkraut or homemade yogurt at home or by purchasing a (more expensive) supplement.

You may have discovered during the intake that your client is interested in changing her diet, but her family members are not willing or eager to do so. The failure to participate in a whole health program by the family is a sure recipe for failure. You may, therefore, choose at this stage to engage the family in a session or more that informs and educates them about the needs for these changes and that gains their agreement. Finally, as you work with your client, you may find that she will benefit from group support even more than individual counseling, and she can join your food-mood support group.

In the report, I provide narrative sections that include the following:

• Symptoms and complaints

• A list of the goals for change the client named during the intake process

• Three short-term action items of change

• Three medium- and long-term action items of change

• Sample dietary suggestions that are isomorphic to the client

• Basic diet or food guidelines including metabolizer type and ideal range of food ratios

• Suggestions for additional testing

• Nutritional supplement protocol

• Additional resources and handouts including special recipes or suggested reading

Principles of Dietary and Nutrient Recommendations

• Start with where you will observe the fastest and most important changes first.

• Start slowly and build according to adherence capacity.

• Always balance the use of vitamins, minerals, botanicals, and glandulars.

• Review and change the protocol every 3–6 months (or as necessary).

• Combine nutrients where possible to include powders and liquids or reduce the number of pills and capsules required.

Stage of Change 1: Precontemplation

The earliest stage of precontemplation is where clients may not want to change, may be unaware that they need to change, or may feel helpless to change (Herrin & Larkin, 2013, p. 99). Linking the results of the Food-Mood diary is a place to begin as clients start to make connections between mood and food choices and behaviors. This is where I began with Joan the first week as we reviewed her diary. Small incremental changes bring fast results, like a high-protein, low-carbohydrate diet for 7 days to stabilize her blood sugar. The assessment process can also be divided into sections to address relevant symptoms or behaviors so that once the veil of avoidance is lifted your clients do not feel overwhelmed.

The Elicit-Provide-Elicit Techniqu e

At every stage of my consultations with clients, I apply methods that actively engage the client in the change process. The Elicit-Provide-Elicit (E-P-E) technique, presented by Miller and Rollnick (2012) in the motivational interviewing approach, is a way of determining what level of understanding the patient already has regarding the changes she could be making and to clarify misconceptions where needed. It also addresses obstacles to change and allows the practitioner to help the patient find a way to integrate the changes. There are three parts to the E-P-E technique:

Elicit: Asking the patient directly what it is that they already know.

Provide: Clarifying any misconceptions or lack of knowledge they may have.

Elicit: Exploring what this information means to the patient.

Joan’s story continues from Chapter 3 , Sample Dialogue 2: Food-Mood Diary.

Joan and I discussed her use of poor-quality fats that emerged during the Food-Mood diary and assessment. This is an important first step that can educate her about eliminating the poor-quality fats and substituting them with the good-quality fats, and it identifies a little further the challenges Joan may experience.

Following is an example of how the E-P-E technique worked with Joan to support her use of better quality fats and oils for mental health and elimination of trans fats.

Elicit (Clinician): Joan, I’m curious about what you already know about the effects of fats and oils on depression.

Joan: Well, I heard that some fats are good for you and some are not, but I am not sure which are which.

Provide (Clinician): You are exactly right; there are differences between good fats and bad fats. We now know that good fats improve mood and can help depression, while bad fats can contribute to depression.

Joan: It seems like what they tell us is always changing and it is confusing, so I just don’t do anything.

Asking for permission to provide (Clinician): It certainly can be confusing! Would it be helpful if I tried to simplify it a bit for you?

Joan (nods): Yes, please do.

Provide (Clinican): Some things we may have heard about fats in the past, such as butter being bad for you, turn out to be untrue. And now we know that eliminating a lot of fried foods and fast foods is healthy, and eating good quality butter and extra-virgin olive oil and coconut oil is very helpful for the brain and mood.

Joan: That makes sense. But seems like it could be expensive.

Elicit (Clinician): Sounds like you would be willing to make some changes as long as they’re not too expensive. We have discussed both eliminating unhealthy foods and adding in some healthy ones. Of the options we discussed, what could you see yourself doing at this point?

Joan: I think if I could do it one thing at a time and find some ways to still enjoy food and treats, then I wouldn’t feel deprived. Perhaps if I started with just replacing my processed snacks with those that have these healthier fats.

Provide (Clinician): Joan, I think changing one thing at a time is a great plan and you may be pleasantly surprised that you will still enjoy many of your favorite foods and not feel deprived. And you seem very committed to improving your physical and mental health, so I think you will be successful. What other questions do you have before we end today?

NOTE: Adapted dialogue from Susan Butterworth (2010), Health coaching strategies to improve patient-centered outcomes, The Journal of the American Osteopathic Association , 110(4), Suppl. 5, eS12–eS14.

Box 9.1

HAPIfork

The HAPIfork is a biofeedback, electronic fork that helps you monitor and track your eating habits. It also alerts you with the help of indicator lights and gentle vibrations when you are eating too fast. Every time you bring food from your plate to your mouth with your fork, this action is called a “fork serving.” The HAPIfork also measures:

• How long it took to eat your meal

• The amount of “fork servings” taken per minute

• Intervals between “fork servings”

Assessing Importance Technique

Another important technique introduced by Miller and Rollnick (2012) involves “Assessing Importance.” This provides an opportunity to enhance client motivation to adhere to the nutritional program. This method allows you to score the importance a client assigns to her or his behavior on a scale of 0 to 10, evoke change talk, and then identify what can increase a level of importance for a required change of behavior.

An example of the Assessing Importance technique with Joan is as follows:

Clinician: Joan, we have reviewed some of the changes you can make about the use of good fats versus bad fats. I’d like to hear a little more about where you feel this change fits in to your life currently. Would that be okay?

Joan: (Nods.)

Clinician: On a scale of 0 to 10, with 0 meaning not important at all, and 10 meaning the most important thing in your life, where would you rate the importance of replacing bad fats with good fats in your diet?

Joan: 8.

Clinician: That’s pretty high! Why are you an 8 and not a 2 or 3?

Joan: Well, I do like the taste of virgin olive oil, although is can be expensive.

Clinician: Why else?

Joan: It’s good to hear that butter isn’t all that bad for me, because I’ve always liked it and it’s cheap and easy to use.

Clinician: Why else is this so important to you?

Joan: I’m intrigued by the thought that these changes could actually help my moods. And it’s really important for me to feel better in that way.

Clinician: Ok, so although cost is an issue for you, you seem to have a lot of good reasons for making these changes in your diet, especially starting with the butter and olive oil. How confident are you that you could make these changes?

Joan: Oh very confident—it really won’t be that hard.

Clinician: So where does this all leave you? What is your next concrete step?

Joan: Well, I’m going to buy butter at the store for sure and check out the cost of olive oil to see where it’s cheaper. And I’m going to try to buy some healthier snacks like we talked about as well.

Clinician: I can hear the excitement and commitment in your voice! I look forward to checking in with you next time to see how it all went.

NOTE: Dialogue adapted from Susan Butterworth (2010), Health-coaching strategies to improve patient-centered outcomes, The Journal of the American Osteopathic Association , 110 (4), suppl. 5, eS12–eS14 .

Stage of Change 2: Contemplation: Acknowledging That There Is a Problem but Struggling with Ambivalence

This is the stage where Joan is positioned and I suspect will return to with each change she contemplates making. In the contemplation stage, Joan considers the positive reasons for change. If I eat less fast food and cook for myself more, for example, I will have more energy and will feel better. On the other hand, it will take a lot more time and energy just to get started. And, of course, there are the obstacles to enacting that change. This is where we work with the ambivalence (Herrin & Larkin, 2013).

The Evoking Change Talk

Evoking change talk is a cornerstone of motivational interviewing and is designed to engage the client to identify reasons to change and elicit a plan of action in at least one area according to the patient’s readiness to change. The objective is to evoke the patient’s desire, ability, reasons, and need to change in order to strengthen the patient’s commitment to the behavior during a session. This “change talk” predicts increased commitment strength to the lifestyle change, which is directly correlated with clinical outcomes.

Clinician: Joan, what might be the top three benefits to you if you changed over to healthy fats?

Joan: Well, I think you said it was better for my brain and might prevent memory loss, so that is important to me. I also think my skin would look better, and I believe I might be in a better mood more of the time.

Clinician: How would your life be different in 6 months if you were consistently making choices to eat healthy fats?

Joan: I have been so moody and fatigued that I would expect in 6 months I would have more energy and not be so depressed. Plus I would feel more in control of my life.

Clinician: Wow, that’s a pretty powerful statement: feeling more in control of your life. How would that impact you?

Joan: It would impact everything—my confidence, my self-esteem, my relationships, my anxiety.

NOTE: Adapted dialogue from Susan Butterworth (2010), Health-coaching strategies to improve patient-centered outcomes, The Journal of the American Osteopathic Association , 110 (4), suppl. 5, eS12–eS14.

Stage of Change 3: Preparation/Determination

Taking Steps and Getting Ready to Change

The preparation or decision-making stage of change is where action will be undertaken within the next 1–2 months. This is where specific goals and strategies are identified (Herrin & Larkin, 2013). Joan has identified some actions she can take, and these will be reinforced at each of our meetings.

Stage of Change 4: Action/Willpower

This stage of change is about acting on behavioral strategies in specific and practical ways. Joan will engage in menu planning, make new purchases, and may begin to identify who in her life can support her. She may also update her Food-Mood diary that we can review when we meet.

Stage of Change 5: Maintenance

The maintenance stage is still in Joan’s future. Her incremental changes with healthy fats may become solidified over the next several months. We will review obstacles to using quality fats, such as eating out or being a guest, and explore how to cope with these challenges while processing any triggers for relapse (Herrin & Larkin, 2013).

COACHING FOR ADHERENCE

There are as many styles of coaching as there are psychotherapeutic styles, and how we coach our clients generally derives from our own approach to counseling. Like therapies, coaching styles should be congruent with the clients’ belief systems. Coaching styles can reflect their stage of change, fit their personality, or nudge them gently in a new direction. I prefer an eclectic approach that integrates self-coaching, which supports the client’s inner voice or inner coach; is solution focused, which identifies specific actionable changes; and incorporates mindfulness, which supports a compassionate, moment-to-moment approach to self change. Mindfulness balances both goals for change with a “no goals” approach. I also use a little directive coaching when appropriate; when a client’s belief in what is possible is flagging, or if the client doubts certain effects, I use a directive approach sparingly, like one adds sea salt to a meal: “If you make the changes I am recommending, you will get better,” “I have no doubt that if you do this you will improve,” “If you make the commitment, you will see the results.” Clients always benefit from unconditional positive regard, but sometimes they also need firm reassurance in spite of their doubts.

Box 9.2 describes simple table designs that support desired behavioral changes.

Box 9.2

Plates and Colors

The size and color of dinnerware affect how much you eat. Smaller plates reduce portion size. Colors that contrast the food on the plate will help you to eat less, and plate colors that match the food will help you to eat more. Tablecloths with a low contrast to plate color will reduce the desire to overeat (Van Ittersum & Wansink, 2012).

Break Down Expected Costs on a Daily or Monthly Basis

Finances are often a concern in making healthful changes. For example, Joan expressed concern that cost was a factor in her decision about changing over to olive oil. It is important to work with your client creatively to reinforce the medicinal benefits of healthy foods and nutrients. Adopting preventive strategies may significantly reduce the costs for health and medicine. Most nutritional products are sold at retail prices that are generally marked up by 100% of the wholesale price. If you coordinate with a nonprofit cooperative purchasing, a wholesale club, or tribal clinics/pharmacies, it is possible to secure the very highest quality nutrients at wholesale prices. This makes them more affordable for your clients with very little markup. Occasionally a physician can prescribe vitamins and oils for diagnoses such as fish oil for major depression, and insurance companies will cover the costs. Many companies will provide product samples that you can share with your clients. Box 9.3 identifies a variety of “tips” to save money while shopping for high-quality foods.

Box 9.3

Money-Saving Shopping and Food-Buying Tips

• Join a CSA or volunteer at a co-op or farm and get reduced prices.

• Day-old bins at the supermarket often have vegetables that make good soups.

• Healthy food is most often on the perimeter of the supermarket.

• Buy in bulk .

• Buy bones and cheap cuts of meat for flavoring and making broths for soups and to sauté.

• Fresh produce is lowest in price when it is in season.

• Shop at ethnic food stores, where they often have less expensive herbs, fresh roots, and low farm-to-store pricing, including Mexican, Asian, Indian stores, and more.

• Buy frozen foods like berries to save money and retain quality.

• Shop so that half of your plate is fruits and vegetables.

• Leafy greens like kale, chard, collards, spinach, and broccoli are some of the most nutritious, least expensive things you can buy.

• Canned salmon, sardines (boneless, skinless), smoked mackerel, and anchovies are inexpensive alternatives to fresh fish.

• If packaged or canned food has more than four ingredients on the label, then avoid it.

Planning meals by writing up a grocery list in advance will save money and time. There are a lot of useful and easy to use apps for the computer or other instruments. Among these is one called “Cooksmarts” that helps with meal planning and recipes.

Some basic principles of meal planning are outlined next.

Meal Planning

1. Create a list of your family’s favorite recipes and make sure they are easily accessible, whether these are in cookbooks or bookmarked on your browser.

2. Clean and organize your freezer because you will need to make room for leftovers. Having glass storage containers and glass baking dishes will come in handy for storing leftovers. Plastic freezer bags are also useful.

3. Keep track of items that you are running low on or that you need to restock in your cupboards. A magnetized whiteboard on the fridge can be quite handy for this, or even just a notepad that you keep in the kitchen. Be sure to bring this list with you when you go to the store.

4. Keep track of the meals that you will be cooking for the week using a calendar in the kitchen, a day planner, or a magnetized whiteboard. Use this to make notes about things that may need to be done in advance, like thawing or marinating meat.

5. In addition to planning dinner for each night of the week, it may be useful to also plan the other meals of the day, including snacks .

6. Before going to the store, create your list. Look at your favorite recipes and pick out which ones you want to cook for the week. Write down everything that you will need. Make columns for different parts of the store and list the ingredients that you will need from each one. For instance, use columns for produce, bulk, dairy, meat, and frozen food.

7. During the week save peelings from vegetables in a tub in the fridge so you can add them to your vegetable broth.

A common reason that people do not prepare healthy food is because they do not have enough time to cook. Preparing a large, healthy meal on the weekend and cooking enough so that there are leftovers is one way to ensure that there is healthy food available during busy times. Meals that freeze well include broth-based soups and casseroles. When making a casserole, double the recipe and freeze the extra in small meal-size containers that can be defrosted and warmed on another day.

Plan and Prep a Week at a Time

1. Pick a day of the week to organize food and food prep for the week. For example, many of the basics can be prepared on a Sunday and will last the week.

2. Roast one chicken: eat half on Sunday night and the other half can be boned and prepared as a chicken salad for lunch. Add the leftover bones to the bone broth pot. Make a Crock-Pot chicken soup from the other chicken, adding vegetables, onions, and garlic, then strain the broth and use as a base for preparing rice or as a soup later in the week, and bone the chicken and store for later in the week or as a snack.

3. Integrate the family in cooking or plan a potluck or food exchange with friends. If you are making soup, make a double batch and trade it with a friend who is making another soup or casserole.

4. When beginning to cook a meal, think ahead for the next few meals and take any preparation methods into account, such as soaking legumes or nuts, or marinating meat.

5. Wash and prepare your vegetables for the week to have them ready for easy use in cooking or for snacking. Include carrots, celery, broccoli, lettuce, bell peppers, mushrooms, zucchini, and so on.

6. Gather all the vegetables you want for salads and prepare raw salads in jars for 3–4 days at a time .

7. Make a vegetable broth rich in potassium by placing all the stems and ends of vegetables in a Crock-Pot.

8. Peel large amounts of garlic, place whole bulbs in the oven, and bake at 300 degrees Fahrenheit until the individual cloves open. Remove from oven and pull apart individual cloves.

9. Use a Crock-Pot in which you place all your meat bones for bone broth.

10. Fill a baking tray of sweet potatoes and bake; store in the fridge. They can be sliced and eaten cold, made into a custard as a dessert, reheated and topped with butter, or sliced and pan-fried quickly in butter and balsamic vinegar.

11. Steam beets and store in the fridge; you can add yogurt and eat as a snack, or eat sliced over salad.

12. Prepare 2–3 salad dressings, choosing from among the recipes in the appendices, and store in bottles in the fridge (see Appendix Y for Salad Dressings).

13. Prepare several cups of brown rice or another grain, which can be reheated and added to soups or stir-fried as needed throughout the week.

14. Soak almonds and raisins—cover almonds and raisins with water and place in Tupperware. Let it sit overnight. Use as needed.

15. Place a cheese slice and a hard-boiled egg together in a Tupperware for an easy protein snack.

16. Put bone broth in a thermos to have it available throughout the day.

Traveling With Cooler Bags and Thermoses

Having cooler bags with you when you travel allows you to buy healthy foods that are easy to eat on the road, rather than relying on fast food and restaurants for your meals. Fill baggies with water and freeze, and then use these as freezer packs to keep things cool. Good travel foods include hard-boiled eggs; dried fruit and nuts; fresh fruit and raw vegetables; aged hard cheeses; gluten-free or whole grain crackers; canned Pacific wild salmon, sardines, or anchovies; water in glass bottles; olive oil and vinegar to add to salads; a Tupperware filled with fresh greens; Kombucha or herbal beverages in glass bottles; and almond butter.

Tips for Traveling and Eating While on Vacation

1. Avoid high-carbohydrate foods at breakfast and opt for simple protein foods like fried eggs and bacon (note that at hotels and buffets most scrambled eggs come from a premade egg mix and sausage meat has additives, so choose the fruit and hard-boiled eggs when possible and avoid the pastries).

2. Order salad with grilled meat for lunch and ask for simple dressings like olive oil and vinegar/lemon. They usually have it in the kitchen.

3. Choose proteins that are less likely to be mass produced, like venison, bison, or lamb, and choose wild-caught fish (preferably from Alaska).

4. Avoid soups in restaurants as they are usually made with broths high in wheat and MSG.

5. Travel with a small supply of energy bars, almonds, rice cakes, almond butter, hard-boiled eggs, and canned sardines until you can get to a store.

6. If staying with family, you can buy groceries to contribute healthy options to meals.

COOKING METHODS

The relationship between whole foods, slow or minimal processing, freshness, and good nutrition is unquestionable. But many people do not know where to begin. For many foods, the least amount of processing (raw) ensures the maximum nutrition and healthful benefits while for others a long slow cook or a quick steam is best. Slow cooking in water, boiling, salting, broiling, pickling, roasting, baking, drying, steaming, fermenting, and smoking are the preferable processing methods that ensure maximum nutrition. Frying, deep-fat frying, high-temperature cooking, and preserving with nitrates and nitrites are the most injurious methods and contribute to poor mental health.

Eliminating Microwave Use

Microwaves alter the molecular structure of food and hence its nutritional benefits; therefore, microwave ovens should never be used to prepare food. Microwaves produce unnatural molecules in food and transform other molecules and amino acids into toxic and carcinogenic forms. The “lazy Susan” plate inside the microwave is ideal for the storage of spice and herb bottles.

Crock-Pot

If you have only one appliance in the kitchen, it should be the versatile Crock-Pot. Crock-Pot cooking is one of the best ways to introduce cooking to someone who does not cook or who does not have a lot of time to cook. Using a Crock-Pot is inexpensive, and slow-cooking foods, especially bones, meats, and legumes at low temperatures is the best way to retain nutrients. Always use unsalted butter and sea salt when cooking with the Crock-Pot, and be sure to put meat juices back into sauces and stews—they are rich in “happiness” amino acids.

Blenders

Blenders are the next appliance to buy for making smoothies, sauces, and dressings. High-speed blenders are the best option, as the typical household blenders do not have the ability to process hard foods like nuts and seeds, and will not produce as smooth of a liquid.

PROVIDE RESOURCES

In our work with clients we also may take on the role as advocates for social change and food security. Thus, knowing local resources and referral points for clients will be essential. Guiding them with forms such as their flexible spending accounts and health savings accounts can often cover some of their expenses for nutritional supplements. Certain diagnostic categories also can bring the cost down; for example, a diagnosis of “obesity” will provide support for health club membership.

Community-Supported Agriculture and Home Gardens

Many regions have community-supported agriculture programs (CSAs.) These are local food production farms that also have a centralized area of distribution in urban settings. Volunteering on a farm during the summer brings cost down, and many of these farms also engage in humane animal husbandry, which can supply quality animal-based proteins. Encouraging home gardens, an herbal kitchen with culinary herbs, or just the exploration of the use of herbal roots and leaves is an important start for clients making changes.

COUPLES AND FAMILIES

Mindful eating extends to couples, families, and group activity as well. Even the simple though often forgotten act of eating together as a family and sharing news of the day leads to reduction of weight gain compared to families who watch TV (Wansink & Van Kleef, 2013). How do we get children to participate in healthy nutritional and behavioral changes?

Beginning at age 8, children are at a good point to start helping in the kitchen. Cooking together is fun and involves skill building, including learning math and measurements, geography, chemistry, and nutrition along with patience and teamwork. If your child is studying something in school, why not plan a theme dinner around that geographic location and include ethnic cuisine and invite one of her or his friends, or their family, to participate. The skill of cooking is becoming a lost art and equipping your child to cook is a lasting healthy gift. For example, we have tamale-making night; in addition to the fun group effort, it is an opportunity to talk about tamales and where corn is from, where salsas and chilies are from, as well as coconut and chocolate. Younger children can learn to count by measuring and practice their reading skills by reading recipes.

Cooking With Kids

• Take children shopping so they can help pick ingredients.

• Have healthy snacks in easy-to-reach places for kids to encourage healthy eating.

• Make it fun and exciting to encourage them—play music, have a conversation.

• Make a list of activities for children to help with in the kitchen.

• Make yogurt.

• Make sprouts and watch them grow.

• Plant wheat berries and watch them grow into wheatgrass.

• Make healthy cupcakes.

• Measure ingredients.

• Make Healthy Chocolate Almond Coconut treats.

• Make smoothies.

• Make sauerkraut and then put it on hot dogs.

• Make gluten-free pizza dough and then have a pizza party.

• Use a spiralizer; they are a lot of fun.

Psychoeducation Nutrition Groups

Developing a mental health nutrition group focused on food/mood can be effective for all clients, including those with eating disorders, those in sexual abuse recovery or addiction recovery, and for people with depression or schizophrenia. These groups can also be organized for children with a diagnosis of ADHD and for the elderly.

I have worked with many of these diagnostic specific groups and the basics are the same: Engage people to be more compassionate with themselves; consider the role of food and eating behaviors in their lives; engage a more social psychoeducational approach infused with mindfulness exercises; educate about the second brain; review myths about foods; and reframe food as medicine and share recipes, tips, and support.

This psychoeducational program combines experiential methods of mindful eating with nutrition education and psychotherapeutic exchange and sharing among participants. The groups are limited to 6–8 people and may run from 90 to 120 minutes over a renewable, 12-week series.

A 12-Week Food/Mood Psychoeducational Group Format

• Week 1: Introductions and compassionate goal setting; introduction to mindfulness.

• Week 2: Mindfulness practice; introduction of food/mood diary; further reflection on goals and obstacles

• Week 3: Sharing about the meaning of food and one’s relationship with food; the mindfulness raisin exercise.

• Week 4: Foods in the family of origin/current family; the chewing mindfulness exercise.

• Week 5: Food and the addictions: How do we use food to self-medicate? What are the healthy alternatives to sugar and refined foods?

• Week 6: Food and body image: How do we make decisions about what we eat?

• Week 7: The second brain: Food and digestion. How do we feel when we eat? From mouth to elimination: What foods and nutrients enhance digestion?

• Week 8: Fear of fats; fear of fat.

• Week 9: Making healthy foods; smoothies.

• Week 10: Overcoming obstacles; making a list for support.

• Week 11: Identifying strengths and next steps; plan for final gathering.

• Week 12: Final “party” where each person brings a healthy dish with a copy of the recipe and shares its benefits for mental well-being.

Integrating nutrition into mental health practice is both feasible and essential. It is the missing piece in our work as mental health clinicians. The approaches outlined in this book promise improvement—ranging from the most basic level of stabilizing mood by managing blood glucose levels along with more advanced approaches of medication withdrawal and comprehensive nutrient schedules for the prevention and treatment of chronic illness. Every clinician can make the steps necessary to integrate the approaches I have presented. To do so requires exploring these methods first for oneself, and then initiating the process step by step with willing clients. If the clinician offers these services, people will respond positively. To do this effectively may require collaboration with various other clinicians or more training. A resource list for options is provided in Appendix Z . This, in turn, will lead to a thriving practice in any setting that will enhance treatment efficacy for people of all cultures and ages.

Essential Next Steps

• Work with the client to identify first steps for change.

• Incorporate motivational interviewing into nutritional changes.

• Coach for adherence.

• Provide a written nutritional report and review it with the client.

• Provide specific resources and handouts to support success.

• Consider the role of group support and develop your Food/Mood group.

• Enjoy a healthy meal with family and friends.

To access a multitude of bonus recipes, downloadable
sample forms, and other supplementary resources, visit
http://nutitionessentialsformentalhealth.com