Coaching a Client Through To A Mental Health Referral Using The Stages of Change

Times arise when it becomes apparent to a wellness coach that their client would benefit from working with a mental health professional. The need for referral may be urgent and involve client safety as when there is a threat of harm to self or others. That rare situation is usually more clearly recognized, referral is made and coaching is usually terminated. (“Top Ten Indicators to Refer a Client to a Mental Health Professional.” This can be found in the Wellness Resources section of the Real Balance website: ) (See also this previous post: The Wellness Coach And Referring Clients To A Mental Health Professional: PART ONE – WHEN ( )

More common is the situation where the client raises issues where there is no immediate danger or threat, but rather, there is either a history of unfinished emotional issues, or there are current circumstances that are creating barriers for the client’s effectiveness at succeeding at lifestyle improvement. In such situations, having a thorough working knowledge of the difference between coaching and therapy is essential for a professional coach. The best possible resource for this is this article by Meg Jordan and John Livingstone (

Resolution Vs. Relevance

How is the past affecting the present?

The first step would be for the coach to explore with the client to see if they are currently in therapy for these kinds of issues, or have been in the past. Then, the coach and client may be able to explore if they can coach about these issues, not to resolve them, but to see how they obstruct progress in the client’s efforts at lifestyle improvement. Can they be accounted for and worked with in coaching, or are the challenges so great that they will actually prevent progress in the coaching?

Well-trained coaches can do process coaching. The key here is to seek how the emotions of the client are relevant to the progress they are attempting to achieve in coaching. Perhaps a client repeatedly holds themselves back from engaging in the wellness/self-care activities that the coach and client create as action steps in their wellness plan. As this is discussed an internal barrier is identified that traces back to their family of origin. Perhaps a critical parent harshly enforced that all work must be done before one does anything for one’s self. Now, the goal of doing process coaching around this is not the resolution of all of the feelings and unfinished business with that parent (be they dead or alive). Instead, it is to gain insight regarding how these past learning’s are holding them back today. If the client is able to gain such insight and translate it into action (moving ahead with self-care) then the process coaching is achieving its goal. If the client continues to only process feelings and does not gain insight or does not succeed in shifting their behavior, then, we have probably identified an issue that is significant enough to warrant the encouragement of referral to a counselor or therapist.

In such cases or if the issues are beyond the scope of coaching and are interfering with client progress, then exploring making a referral needs to begin. How to make this referral successfully is not as simple as explaining the benefits of therapy and providing resource information. Very often clients are ambivalent, or even outright resistive to a referral to a mental health professional. The thought of reconnecting with all of the unpleasant emotion involved in working directly on their issues in therapy brings up fear. Unfortunately, coaches sometimes drop such a client quickly when they are not ready to jump into action and seek out the therapy they would benefit from. This is where a client would benefit from a coach who implements a Stages of Change approach (The Transtheoretical Model of Change developed by James Prochaska).

In the new book by James and Janice Prochaska Changing To Thrive (, they make the point that most of the people we all work with are not in the action stage of change on any particular behavior. They estimate that only about 20% are actually ready to jump into action. Why would this be any different when it comes to engaging in counseling or psychotherapy? Yet, so often, when the client balks at following through on a psychological referral, coaching is abandoned. Instead, think of it as our job to help the person to weigh the pros and cons of engaging in counseling as they sit in the Contemplation Stage of Change. We are helping them with Decisional Balance. Taking a page from Motivational Interviewing, we coach as they work through their Ambivalence. We want to “roll with resistance” instead of accepting it as a rejection of our referral recommendation.

Coach THROUGH to referral!

Coach: So, I hear your hesitance when I suggest that counseling might be the best way forward with this.
Client: Well, yes. I’ve been in counseling before and I don’t know if I want to open up that whole issue again.
Coach: Sounds like you possibly have some fear about talking about such uncomfortable subjects again.
Client: Yeah. Growing up in my home was not a pleasant thing!
Coach: I know it holds a lot of negative memories for you. You’ve shared some stories about how bad it was. Yet, I also hear you saying that it’s frustrating to have these things hold you back from doing what you want to do today to be healthy and well.
Client: Right! It’s really frustrating! I know I need to get more active and take more time to eat right, but then I feel so guilty when I take time for myself.
Coach: So, on the one hand you really want to make these improvements to your lifestyle, but when you attempt to do so, these barriers, these thoughts get in the way.
Client: Exactly! I appreciate your help, but it seems like whenever we set up action steps, I never follow through on them, even though I know I need to.
Coach: Yes, we’ve explored how it’s all related, but we still seem stuck. What do you think would be the benefits if you did get back into counseling about this?
Client: Well, I guess I could really open up about it and try to unload some of this frustration. I’m just so tired of having the past hold me prisoner!
Coach: So a counselor could actually help you explore that and really make some progress in this area, perhaps result in some relief.
Client: Yeah. Okay. So what’s next?
Coach: Well, let’s work together on reconnecting you with some counseling. Let’s see what steps you can take to find the resources you need.

In this example the coach meets the client where they are. They help their client to Contemplate the idea of returning to counseling. Acknowledging the client’s fears and validating their feelings, the coach helps the client to begin to weigh the reasons to return to counseling and the reasons to avoid it. The family of origin stories are referenced, but not delved into. Instead, the emphasis is on relevance. How the past is getting in the way of the present is the essence of the contemplation. Then, at the end of the example we begin to move into the next Stage of Change; Preparation.

Coaching works because we are the client’s ally through the whole behavior change process. When referral comes up, we remain their ally. Then to help them actually follow through and make it to the referral resource, we help them with the process of identifying such resources, making the appointment, and attending the appointment. We offer support and accountability with all of the action steps required to achieve this preparation. We acknowledge the courage, the valuing of one’s self that is required for each step along the way.

James & Janice Prochaska with Michael Arloski

Take what you know about the Transtheoretical Model of Change (Stages of Change) and apply it to the referral process. Be your client’s ally when they need you the most.


SPECIAL ANNOUNCEMENT:  James and Janice Prochaska will be Dr. Arloski’s guests on the Real Balance Free Monthly Webinar – May 26 at Noon Eastern Time.  This will be a special one-hour webinar where the Prochaska’s will be sharing their breakthrough work from their new book CHANGING TO THRIVE.

“Changing To Thrive: Using the Stages of Change to Overcome the Top Threats To Your Health and Happiness” An Interview with James and Janice ProchaskaRegistration URL: Registration URL:

Ten Ways To Coach Through Barriers To Change – Part Two – Inner Barriers To Lifestyle Improvement – I by Dr. Michael Arloski.

So often times it happens that we live our lives in chains And we never even know we have the key. (The Eagles - "Already Gone")

Your client has their motivation to be healthy and well energized, they’ve checked out their readiness for improving their lifestyle and, perhaps, with your help, they’ve even gotten a real wellness plan lined out. So, what is getting in their way of taking action and living that healthy lifestyle? Chances are they will encounter some external barriers like schedule changes, lack of support from folks they counted on at home or at work, increased workload, etc. While we can work with them to strategize ways over, under, around and through those, the more insidious barriers can be internal in nature.

What holds us back from succeeding at lasting lifestyle change is often as much an internal challenge as it can be external factors. (See our previous post-–-part-one-–-outer-barriers-to-lifestyle-improvement-by-dr-michael-arloski/) Our own beliefs about ourselves, and the world around us, as well as issues of self-esteem, self-doubt, and self-efficacy, may determine our progress and success. We can all be our own worst enemy without even knowing it.

There are libraries full of evidence that our lifestyle choices do indeed affect our health both in terms of prevention and in terms of the course of an illness. (e.g. Yet, as we know belief is not a simple matter of logic and facts.

1. Address Belief Systems.

Coaching is not consulting so we aren’t just telling our clients they “need” to change their belief systems. Our clients come to coaching with their own values, priorities, and ways of thinking about the way the world works. Coaches honor that. It doesn’t mean, however, we can’t challenge ways of thinking that are self-defeating. Instead of labeling certain thoughts and the resultant behaviors as “SDB’s” (self-defeating behaviors), we need to help our clients examine them. This might best start with a request for clarification “Tell me more about that.” Then the classic “How’s that working for your?” question hopefully jogs our clients into some insight about how self-defeating such thinking really is.

Another barrier to growth and change is when our clients are less than clear about what they truly value, or are living out of accordance with their values. Helping our clients to clarify their values is a huge service that the coaching process provides. Belief systems have deep familial, cultural and experiential roots that aren’t easily ripped from the ground, and shouldn’t be. Our job as coach is to continually facilitate a process of self-examination in our clients and honor their own pace and choices about change. This process continues with all of the remaining ways through inner-barriers we will look at here.

2. Defy Self-Deception

When we don’t understand the motivation of ourselves, or others, we often fill in the blanks with assumptions. When those assumptions are based on fears we are especially vulnerable to deceiving ourselves. If a co-worker interacts with me curtly I might assume that they don’t want to be around me, that they think less of me, or perhaps believe that my job performance is sub-par and they want to only be minimally associated with me. I might then start avoiding interactions with them. This is what the authors at The Arbinger Institute call “self-betrayal”. In their marvelous book Leadership and Self-Deception (, they take on the very challenging task of helping us see what is invisible to us; the ways that our thinking betrays us leading to false conclusions about ourselves, and those around us. Self-betrayal leads to self-deception. Helping our clients to catch themselves when they are basing their perceptions of the world (and themselves) on judgments, prejudices, assumptions, projections and inadequate information can help them shift to not only greater compassion towards self and others, but to more accuracy as well.

3. Build Self- Esteem & Self-Efficacy

When it comes to being successful at losing weight, managing our stress, quitting smoking, etc., your client can start with two questions for themselves: Can I really affect my own health and am I worth it? Psychologist Wayne Dyer is fond of saying “You’ll see it when you believe it.” This is indeed a matter of belief. Do you believe that all of these efforts to improve your lifestyle are going to make any difference in your health (self-efficacy)? Is the effort worth it, and am I worth the effort? The two questions go hand in hand. People who are successful at lifestyle improvement are able to answer “Yes!” to these questions. A “No.” or even a “Maybe.” says that your work needs to start right here.

How “Okay” I feel about myself may have some very deep roots but unearthing them may not be as necessary as you might think. Helping your client to build confidence in themselves and their wellness efforts starts with selecting goals that are the easiest to attain and letting success build on success. Support them as they experiment to attain more mastery in their world. They can increase their probability of success by working with an ally (like you) instead of, once again, attempting it by oneself. They will also, of course, be more successful with an actual plan instead of just launching a single action step effort. Encourage them to seek out experiences that allow you to engage in creative self-expression, another know booster of self-esteem. Build it in to their wellness plan.

4. Gag The Gremlin

Tied into progress at building self-esteem and self-efficacy is being vigilant about keeping our self-doubt and excessive self-criticism at bay. It seems that the little negative voice that whispers inside your ear gets activated whenever you attempt a change. In chapter eight of my book Wellness Coaching For Lasting Lifestyle Change ( I take the reader through the process of learning about their own way of being self-critical and how to combat it. The Inner Critic or “Gremlin” is really that part of us that has internalized falsehoods about us and these thought patterns bring forth our self-doubt and hold us back from action and success. Psychologist Rick Carson’s little book Taming Your Gremlin ( is found to be so valuable by many coaches that they often include a copy in their client Welcome Packets.

How do you keep yourself from taking flight and soaring?

5. Fly With The Eagles (So The Turkeys Won’t Get You Down)

There is no doubt that Peer Health Norms are a huge factor in our lifestyle choices. It is hard to go against the grain all the time and be the only one in our family, group of friends, or workplace who is consciously attempting to live a healthy wellness lifestyle. Albert Bandura talks about “vicarious experiences provided by social models” as an effective way that we can develop self-efficacy. Certainly being around others who are more physically active, eat well, share feelings more easily and value connectedness and seeing their success, will make it easier for us to engage in such similar behaviors.

Our coaching challenge arises when our client is faced with the incongruity of a personal desire to change and an environment that discourages it. We can help our clients by A) encouraging them to ask for the help they need. Support them in having honest conversations with their peers about their intentions to change and their desired goals. Help them enlist support. We can also B) help them build a support network of people who are living more wellness-oriented lives. This may need to be a conscious part of their wellness plan. When our clients face either a lack of support or even push-back from their peers we can help them C) process their feelings about this and develop strategies for dealing with it.

Dr. Arloski will be presenting a Free Webinar on this topic, Feb. 23, 2011.  The recording will be archived Feb. 25th and be available at

Part Two (#6-10) of this piece will be posted in a few days. We invite your comments!

Change: The Paradox of Fear and Attraction Eight Thoughts for Success at Lifestyle Improvement.

When it comes to change...Choose Big!

“Change” is such a powerful and loaded term. The very word brings out any number of wildly disparate responses: fear, anticipation, longing, uncertainty, attraction, loss and excitement. Change in attitude, and belief yielding change in behavior, or more specifically health and wellness behavior is what we’re after. Yet if the very idea of change is at all scary, isn’t that just one more reason not to change?

“Lifestyle improvement” was always the term of the wellness movement until more recently when “lifestyle change” became the buzzword. The cynic could counter with “Well, I’m smoking a lot more now, that’s “change”!” Personally I’d love to get back to the original term, but at the heart of any improvement, is, inevitably change.

Taking on the subject of change is complex with endless possibilities to explore and many great theories about it. I’ve even got some of my own. We’ll look at what we can learn from the broader topic of change and the work of theorists like Albert Bandura and James Prochaska on later posts.

Here’s some of my thoughts, gleaned from many years of helping people make the changes in their lives that they really wanted to see.

1. Change means loss. Even positive changes mean giving something up. “My new smartphone has endless features, but I miss the ease of handling that my old phone had.” “I love the new town I live in, but I wish I was still in Wellville.” “I’m so glad I quit smoking, but you know, there’s nothing like a good cigar!” Sometimes change seems to weigh out more negatively than positive right from the start. It’s OK to acknowledge our losses, and to even grieve them. When we don’t fully grieve, our attachment to what was persists and robs us of our full presence in our new reality.
2. Change reminds us that nothing lasts forever. The transience of life is perhaps the only thing we can all be absolutely sure of. Our attachment to what was is the primary source of our suffering according to one of the basic tenets of Buddhism. Letting go of attachment
requires real perspective on what is truly important to us.

“Everything flows and nothing abides, everything gives way and nothing stays fixed.” Heraclitus (c.540-c.475 BC)

3. Own your choices. When people feel “trapped” change seems impossible, even though it may be greatly desired. I love to teach that a coach’s job is to remind people that they have choices! When someone can accept that they are choosing to remain at a job, in a marriage, or living where they live, for now, until they can improve that situation, everything changes inside of them. Suddenly they can go through the door at work knowing that for now it is the best thing for them, but that they are working on finding either a way to improve that situation or move on to something better. They are free.
4. Change doesn’t always require total abstinence, denial and deprivation. A way to guarantee the failure of a wellness program (at an organizational or personal level) is to make it all about giving up one’s current ways of living. “You folks have to give up your smoking, drinking and eating all of that Bar-B-Que!” Those words were the kiss of death for one wellness program I knew of. Most weight-loss programs recognize that when people feel deprived of what they truly enjoy (You can NEVER have ice cream again, as long as you are on the planet!) they fail at their attempts to lose weight. Perhaps a 100% abstinence is the right thing for you and your psychophysiology (maybe alcohol or sugar?), but as long a we keep track of our behavior and minimize self-deception, we can ease our way into change incrementally.
5. Change can be joyous! As fearful as we can be of messing with the status quo, the benefits of positive change, especially lifestyle improvement, bring joy to our lives. It’s kind of like what you learn about conflict and conflict resolution. Change is an inevitable part of life. Change is not inherently bad. Change is, in fact, an indicator that an organism is alive!

“He who’s not busy being born, is busy dying.” Bob Dylan

6. Change is not just about “will power”. Determination helps but is far from sufficient for lasting success. This is the classic “New Year’s Resolution” approach to change. Pumped up and poorly thought-out. It’s the reason you can always find an exercise machine readily available at the health club come March or April. If we’re changing old behavioral or cognitive habits they will re-emerge. This is not evidence that we are weak and lack enough “will power”. It’s evidence that we are truly engaged in the process of changing life-long habits.
7. Be true to your own beliefs and values. Make changes that are your changes, not someone else’s. Let celebrities live their own lives, even wellness gurus. Find your own ways of improving your life that are completely congruent with who you are. Discovering more deeply who you really are, what values truly reside in you, may be your most important first step towards effective change. Changes in behavior flow from changes in belief.

8. Sometimes “lifestyle change” means changing your life. Lifestyle changes can be pretty cosmetic at times, yet we struggle even to make those improvements succeed. Maybe it’s not about twenty pounds, or bigger biceps. Maybe it’s about being happy, content, and comfortable inside our own skin. Perhaps it’s about unconditional friendship with ourselves ( to reference Pema Chodron. Perhaps it’s about getting some great career guidance, making that move to where you really want to live.

Blogger Leo Babauta (Zen Habits) who writes beautifully about living a fuller, and more effective life recently posted this excellent piece on change. He encourages us to embrace change and find the joy in it!

When it comes to succeeding at lifestyle improvement, what are the elements of change you would add to our discussion here? What has really helped you to step forward into change and find the benefits and joy of it? Please leave a comment, and be well!