Great coaching finds a balance between structure and spontaneity, customization, “dancing in the moment” and organization. While some large coaching organizations err on the side of too much structure, using scripts and ridged protocols, some coaches “wing it” way too much. Listening to hundreds of coaching recordings, done with real clients, I’m continually amazed at how loosely many coaches go about their work. Observing the variance in structure, or lack thereof, led me to create some suggestions for how you can discover the benefits of coaching structure for your coaching sessions.
1. Every Session Is A Small Part Of A Whole
Think of each coaching session as part of the larger coaching process and relationship. Keep the individual session in the context of the entire work you are doing with that client.
First sessions, or what we often call Foundation Sessions, or Discovery Sessions, are unique in that they are all about Co-Creating the Coaching Alliance. In this first session there is a lot to do in addition to listening to the client’s story. Typically, two to three times longer than a regular subsequent session, these sessions allow for getting acquainted, creating agreements about the coaching, familiarization with the client’s story, their concerns, etc. The number one error in Foundation Sessions is to get caught up in the story and take a problem-solving approach right out of the gate. Clients benefit much more from you two building the coaching alliance, taking stock of their wellness, and getting clear about how coaching works.
Regular coaching sessions also need to be thought of by the coach in terms of the larger coaching process. Is this one of the early sessions, or are we starting to work towards termination? Coaching does not go on forever and many coaching contracts involve a limited number of sessions. Also, how does this session fit in to the overall Wellness Plan that you and your client have formulated? How does the “issue” that they just brought up today have relevance to their Wellness Plan?
2. Co-Create The Agenda At The Beginning Of Every Session
Certainly, one of the most common errors coaches make is to start a session with a vague invitation like “So! What do you want to talk about today?” Most often client’s immediately think of some sort of barrier they would like to deal with and coach and client instantly begin a problem-solving discussion. I’ve actually heard coaches begin a session with the even more vague request, “What’s up?”. If a specific problem doesn’t jump to the client’s mind, the client might flounder for a while until lighting upon a topic to discuss.
This approach conveys to the client that the coach is a consultant with whom to solve problems instead of an ally in a process of growth and development. This is where some co-creating the agenda first sends a very different message as well as setting up the session for success.
What works best is a discussion of what all will be talked about in the session and what the client wants to get out of the meeting together. ICF (International Coach Federation) examiners are looking for this kind of review and agreement at the beginning of every coaching session. Just like in a team business meeting, co-creating the agenda means taking in all of the topics to be discussed and then setting an agenda based upon strategy and priorities. It’s best to go with a reasonable blend of urgent and important, remembering that not everything is, in fact, urgent and important.
3. Make Checking-In About Wins And Go Beyond Just Hearing Reports
Begin with Wins!“Tell me about some progress you made in improving your lifestyle since we last talked?” Coaching is an inherently Positive Psychology approach designed to build upon strengths. Make good use of that. Acknowledge those wins. Don’t just say “Okay.” Inquire more about them, request clarification.
Transition from Wins into checking-in on the accountability agreements that were made last time on action steps. As you do, urge your client to go beyond just reporting what they did. Begin to help them explore those actions to gain greater understanding of what worked and can be reinforced, what didn’t and what got in the way. Look at how you can facilitate your client’s exploration of their actions and themselves. Head into new territory and watch your client grow!
4. Once You’ve Got A Wellness Plan Navigate By It
The map you navigate by, once you co-create it with your client, is the Wellness Plan. Now, whatever comes up in coaching is always put in the context of its relevance to the Wellness Plan. The plan is flexible, changeable, but if you want to get results, you continue to follow it. This is where time is saved by steering back away from tangents and irrelevant topics. This is where “What do you want to talk about?” becomes obsolete. Ask yourself, and perhaps your client “Are we still on the map?”
5. Process – But Don’t Get Lost In It
The bulk of most coaching sessions is about processing the client’s efforts at implementing the Wellness Plan. You and your client can have a lot of fun strategizing through barriers, coming up with creative approaches to making progress on goals, and more. The mistake most coaches make it to use 90% of the session doing just this and not leaving enough time for Next Steps. It’s so easy to “get into the weeds” where “the devil is in the details” and get lost. Stay focused and get back to the backbone of the process – the Wellness Plan. Problems become about relevance to the plan. Problems from the past become about relevance (how are they affecting implementing the Wellness Plan in the here and now), not about resolution (that’s the job of therapy).
6. Leave Time For Next Steps
Effective coaches are watching the clock and know to leave about one-third of the session for Next Steps. Processing until there are only five minutes left is a sure way to set your client up to struggle instead of leaving with a clear plan of how to move forward and make progress. Look at what’s working and what needs to be adjusted. Create agreements about the action steps the client is committing to for the time between now and the next session. It often comes down to Reset, Recommit, or Shift. Will they benefit from resetting the level of the action step – going from walking 5x/week to 3x/week? Or, is the best strategy to re-commit to the same action step at the same level for this week? Or, is it best to strategize a shift to a whole new action step? That will require adequate time to do well.
7. Pick The Music But Stay Light On Your Feet
Coaching structure provides the framework for progress. It is like the music that the coaching couple picks to dance to. Coaches perpetually use the expression “dancing in the moment” for good reason. Don’t be afraid to let go of the structure of a session in order to deal with what is more important. Your client may need your support in dealing with a very emotional issue. There may be something that needs to be confronted about the way the two of you are coaching together that may be critical to progress, or even the continuation of coaching. If the coaching seems stuck and progress is lacking, have the courage to explore with your client how the two of you can work better together. Shift the dance of coaching to deal with what has emerged, but then, get back to the music and the structure that will facilitate the progress your both want to make.
Most clients who struggle with medical adherence and/or the lifestyle improvements recommended by their treatment team (the Lifestyle Prescription) benefit from the structure that wellness coaching provides as well as the power of the coaching alliance. Clients are attempting to adopt new behaviors, shift from old unhealthy behaviors, and often reorganize their lives radically to do so. They benefit from co-creating, with their coach, a well-designed plan that addresses their overall, total wellness, and makes medical adherence a part of it. It becomes just one Area of Focus in a fully-integrated Wellness Plan.
Health and wellness coaches who work with clients challenged by chronic illness, and even more acute medical challenges, are counted upon to help with medical compliance and adherence. The clients themselves count on them because they struggle with medical self-testing, taking medication properly, following up with appointments, exercising, and whatever the recommendations of their “lifestyle change prescription” are. Coaches are also counted upon by those providing healthcare services, insurance services, employee benefits and more, to help manage costs through better overall patient compliance/adherence. This often becomes a large part of a wellness coach’s job.
The job is valued because the need is great. First of all, when clients fail to take their medication properly, manage their blood sugar levels well by doing their self-testing regularly, etc., they suffer. There are more hospitalizations and trips to the emergency room, more chance of complications and usually more progression of progressive diseases.
The Network for Excellence in Health Innovation calls improving patient medical adherence a $290 Billion Opportunity. (https://www.nehi.net/bendthecurve/sup/documents/Medication_Adherence_Brief.pdf) that’s what is lost in U.S. healthcare spending each year due to poor medication adherence alone. The same source goes on to say that “when patients with severe or chronic conditions do not take their medications, the consequences can be extreme. Clinical outcomes are highly affected by non-adherence. For example, those with 80-100 percent adherence rates are significantly less likely to be hospitalized than their counterparts.”
Lack of follow through on medications, and other types of “following doctor’s orders” can be due to many different reasons, some of which are not the fault of the patient. Cost of prescriptions and supplies in the United States is often a big factor. Inadequate instructions from the healthcare provider, a lack of self-care education, access to treatment and/or education, plus costs, account for about 31% of the reasons for poor adherence. The other “69% of the problem is behavioral, such as perceived benefits, poor doctor-patient relationship, medication concerns, or low self-efficacy.” (http://www.dtcperspectives.com/impact-behavioral-coaching-adherence/#_edn3).
A note on terms:
Non-compliance — not complying with medical directives, prescriptions, etc. A patient decides that their physician is basing a prescription on inadequate information and decides not to take prescribed statins. Non-compliance — More of a refusal, a decision. Can be medical or lifestyle prescriptions. May be due to external causes (like cost). More authoritarian. Non-adherence — not following through consistently with the treatment plan including the “lifestyle prescription”. Not adhering to the plan. More likely due to inabilities, difficulties executing the plan, etc. You will also find that the terms are sometimes interchangeable in the professional literature.
Research on health and wellness coaching has shown significant effectiveness in improving this problem. Unfortunately, most of the research narrowly focuses on one research variable, one aspect of medical compliance/adherence – medication adherence. In a study of the impact of health coaching with patients with poorly controlled diabetes, hypertension, and/or hyperlipidemia, “Health coaching by medical assistants significantly increases medication concordance and adherence.” (1) Ruth Wolever and Mark Dreusicke (2) found that integrative health coaching led to an increase in medication adherence and that better adherence correlated with a greater decrease in HbA1c (blood sugar measure).
Many of the studies are gleaning what appear to be the coaching methods that make a real difference in effectiveness. Wolever and Dreuskicke concluded that “Medication adherence requires underlying behavior skills and a supporting mindset that may not be addressed with education or reminders.” So, though helpful, clients/patients often need more than just text messages sent on their smart phones. Amanda Rhodes, in a 2017 article (3) takes on a more corporate perspective in showing how coaching is beneficial to both patients and the pharmaceutical and healthcare companies that serve them. What their research emphasized was how client-centered the whole approach needs to be. “Patient-centered behavioral coaching is designed to help patients determine the way in which THEY believe they need to change their behaviors to achieve their goals. Patients who feel listened to are more comfortable with the care they receive and are more likely to adhere.”
Alliance Over Compliance
For the health/wellness coach and the client they serve, the heart of the matter is the coaching alliance. As seen in the articles we’ve spotlighted here, adherence comes not from medical admonishment or authoritarian directives. It comes from a client/patient developing self-determined goals that they are motivated to pursue. It comes from having an ally to help them navigate through the barriers that they face to achieving the high level of health and wellness that all people want. The coach may be well aware of the medical urgency for a client to, for example, quit smoking, or take their medication properly. But, as we’ve learned from all forms of behavioral change efforts, the process, ultimately, must be self-directed. That is, the client has to see the value in making the change, be ready to make it, and have both a concrete plan of action and the support they need to achieve it. Tempting as it may be for the coach to become extremely directive and take over the action planning, they must remain in a true coaching mindset and be the ally the client needs in their own process. This requires patience, but as is often the case, patience pays off.
A Fully Integrated Wellness Plan
The client and coach work together to determine what the other Areas of Focus will be, based upon Readiness for Change Theory, the directives of the Lifestyle Prescription, the values and interests of the client, and all of the exploration and assessment that the coach and client have done together. Other Areas of Focus could include such things as: Attaining & Maintaining A Healthy Weight; Smoking Cessation; Achieving Greater Social Support, etc.
Areas of Focus break down into Goals and the specific Action Steps that the client will engage in to achieve those goals. All of this is co-created, not dictated.
Coaching Does What It Is Good At
In the focus on medical adherence, coach and client co-create a way to identify the specific behaviors that are needed to either develop or change. They then, strategize the best Action Steps that will be an optimal starting point for success. They develop tracking strategies, so the client will know when they are being successful at doing their self-testing regularly, taking medication on time, staying organized enough to follow through on medical appointments, etc. The key to tracking, whether done on phone apps, or good old pencil and paper is following up with Accountability on it. Sending the coach app or text messages, or simply reporting in at the next coaching appointment will help the client feel accountable to themselves to achieve what they, themselves, want to get done. The coaching alliance also takes on the myriad barriers, both internal and external that get in the way to solid medical adherence. Strategizing through barriers such as a lack of family or workplace support, checking out fearful assumptions (especially about side-effects), all increase the likelihood of success.
There are times when we see a complete shutdown of efforts to follow the directives of the treatment team, especially around the lifestyle changes that are urgently needed to shift. This refers to a client paralyzed by grief over their perceived loss of health. To understand this check out our previous blog post – “Astonishing Non-compliance – Understanding Grief and Readiness for Change in the Health Challenged Client” (https://wp.me/pUi2y-n2 ).
The Many Faces of Medical Adherence
Coach with your client to determine what the components of medical adherence are for them. Don’t just focus on medication. Help them see that their best strategy is to live their healthiest life possible in all dimensions of their wellness.
(1) Thom D, Willard-Grace R, Hessler D, DeVore D, Prado C, Bodenheimer T, Chen E. The impact of health coaching on medication adherence in patients with poorly controlled diabetes, hypertension, and/or hyperlipidemia: a randomized controlled trial. J Am Board Fam Med. 2015 Jan-Feb;28(1):38-45. doi: 10.3122/jabfm.2015.01.140123
(2) Ruth Q Wolever, Mark H Dreusicke.
Integrative health coaching: a behavior skills approach that improves HbA1c and pharmacy claims-derived medication adherence. Clinical care/education/nutrition/psychosocial research. https://drc.bmj.com/content/4/1/e000201
• Sforzo, Kaye, Todorova, et al. (2017). Compendium of the Health and Wellness Coaching Literature. American Journal of Lifestyle Medicine,1559827617708562. http://journals.sagepub.com/doi/full/10.1177/1559827617708562
• Ruth Q. Wolever, Making the Case for Health Coaching: How to Help the CFO Understand — Real Balance Coach Center – April 2018 Free Monthly Webinar.
• https://ichwc.org/resources/ “A Systematic Review of the Literature on Health and Wellness Coaching: defining a Key Behavioral Intervention in Healthcare” (Resources section for ICHWC)
“Don’t get too close to your clients.” It may have been my junior year of being an undergraduate psychology major when a professor offhandedly gave this warning to me and a couple of other students. There is always this question about ‘therapeutic distance’. Clearly when a therapist allows their own feelings of attraction or repulsion, insensitivity or caring to interfere with the ability to deliver effective therapy, we have a problem. Therapists may wall themselves off from connecting too closely to protect themselves from the pain of their client’s suffering. At the same time, therapists are exhorted to empathize, to connect genuinely, authentically, to allow a therapeutic closeness to grow. They are often left in this ambivalent quandary of just how “close” to be to their client.
The coaching relationship is not intended to be a therapeutic one, even though it may contribute to a client’s own healing. Many experiences are therapeutic and the experience a person has with coaching may be just that. However, our intent is not to heal the old wounds of our client, but to be their assistant in their personal growth. The coach’s quandary is similar to that of the therapist, but also different. Without the ‘therapeutic distance’, it may, in fact, be even more confusing. If we are not delivering treatment with our client, then, are we more like a friend? We will hear stories of suffering. How do we protect ourselves from feeling their pain as our own?
Coaches may start to find themselves becoming more reluctant to truly engage with their clients. They may find themselves pulling back emotionally and fighting the urge to connect more closely. Hearing another story of difficulty, failure, conflict, or even trauma, abuse and neglect, we may react by diminishing the very coaching presence that is essential to helping our client to work through their challenges. The coach may find their ability to concentrate and really listen to our clients becoming reduced. It may show up physically with difficulty sleeping, a drop in our immune response, headaches, digestive issues, and much more. Our ability to be compassionate may be just worn thin.
An ICF published article by Niamh Gaffney (https://coachfederation.org/blog/are-you-tired-of-coaching) defines Compassion Fatigue as “a combination of physical, emotional and spiritual depletion associated with caring for people in significant emotional pain and physical distress.” The term depletion is perfect in this description. Our own well feels like it has gone dry, or soon will. It may feel like our very soul is being drained. The way out of compassion fatigue is the same as preventing it.
Operating From A Coach Approach
Failing to recognize the difference between coaching and counseling or therapy leads coaches to delve into an attempt at therapeutic problem solving. We may disguise it to our client and ourselves as “working on stress”, but if we approach stress management by attempting to solve all of the problems that generate stress in our client’s life, we are engaging in an infinite exercise in futility. Not only does it not work, it is exhausting for both client and coach. Your client may sense the futility before you do and leave coaching entirely.
Maintaining a coaching mindset is essential here. Can we help our stressed-out client to learn how to deal with stress, and to recover from stress instead of infinite problem solving? When coaches ask “What issues do you want to work on?” they are inviting the beginning of a therapeutic expedition. When we see ourselves as our client’s ally, not their doctor, healer, priest or therapist, we take a stance of closeness and caring but with less of a feeling of responsibility for their solutions and ‘cure’.
In wellness coaching, instead of operating on a problem du jour model, we work with our clients to help them take stock of their current health and wellness, create a vision of their best life possible and then co-create with them an effective wellness plan. Operating from a plan is totally different than continual problem solving. Certainly, we engage in strategic coaching with them to address barriers, but our job is not to provide solutions. Compassion fatigue, I believe, comes sometimes from the sense of powerlessness that we may feel when we can’t provide the magic solution for our clients that will make their lives better. When we realize that doing so is not our job, we can allow for more of a healthy compassionate detachment to take place.
Twenty-seven years or so of doing psychotherapy with a wide variety of clients had its joys and challenges. Upon hearing the detailed recount of a young woman or man who had been abused sexually by a parent, I couldn’t just go home saying “It’s only a movie.” Clients come needing to tell their stories to a therapist who is not afraid to go absolutely anywhere with them. A really good therapist learns to be a true warrior/warrioress of the heart who is completely fearless. Yet, the only way they can go into battle again, side by side with their client is by learning something about compassionate detachment.
We practice compassionate detachment for the benefit of our client and for our own benefit as well.
Compassionate detachment is respecting our client’s power enough to not rescue them while extending loving compassion to them in the present moment. Simultaneously compassionate detachment is also respecting ourselves enough to not take the client’s challenges on as our own and realizing that to do so serves good purpose for no one.
Compassionate detachment is an honoring of our client’s abilities, resourcefulness and creativity. We remain as an ally at their side helping them to find their own path, their own solutions. We may provide structure, an opportunity to process, a methodology of change and tools to help with planning and accountability, but we don’t rescue. As tempting as it is to offer our suggestions, to correct their errant ways, to steer them toward a program that we know works, we avoid throwing them a rope and allow them to grow as a swimmer. Sure, we are there to back them up if they go under or are heading toward a waterfall. We are ethically bound to do what we can to monitor their safe passage, but we allow them to take every step, to swim every stroke to the best of their ability.
To be compassionate with a client we have to clear our own consciousness and bring forth our nonjudgmental, open and accepting self. We have to honor their experience.
“Only in an open, nonjudgmental space can we acknowledge what we are feeling. Only in an open space where we’re not all caught up in our own version of reality can we see and hear and feel who others really are, which allows us to be with them and communicate with them properly.” Pema Chodron, When Things Fall Apart
Compassionate detachment is also about giving ourselves permission to protect ourselves. Being in proximity to the pain of others is risky work. There are theories about the high rates of suicide among dentists based on this. Compassionate detachment is also about being detached from outcome. We want the very best for our clients and will give our best toward that goal, but we give up ownership of where and how our client chooses to travel in the process of pursuing a better life. Their outcome is their outcome, not ours.
Compassionate detachment is not about distancing ourselves from our client. It is not about numbing ourselves out mentally, emotionally or physically. It is not about treating our clients impersonally. That is mere detachment alone and more a symptom of burnout than of good work as a coach, therapist or any kind of human helper.
Intimacy is what allows compassion. When we fear closeness, we will hold back. We will be less empathic because we fear connecting with our own feelings. Compassionate detachment is being centered enough in ourselves, at peace enough in our own hearts, to be profoundly present with our clients in their pain and in their joy as well.
From Depletion To Replenishment
If compassion fatigue is about feeling depleted, then prevention and recovery is about replenishment. Fatigue comes from the expenditure of energy: physically, emotionally, and spiritually. Coaches must ask themselves what they are consciously doing to restore their own energy supplies. Once again, we are talking about the coach’s own Wellness Foundation.
We often think of wellness in terms of exercise and participation in all kinds of wellness activities. To what degree are these activities an expenditure of energy, and to what degree do they provide an energy return and replenishment. While a workout resulting in a “good tired” feeling my fatigue us physically, it may invigorate us mentally, emotionally, and even spiritually. Once again it is a matter of balance. Are we engaging in mind/body activities that replenish our energy on multiple levels? Mindfulness practices, meditation, Tai Chi, Xi Gong, Yoga, all share the intent of this kind of replenishment.
Our Wellness Foundation is not just about working out and eating well. What we are looking for here is replenishment on the levels at which we are being depleted: more the emotional, mental and spiritual. Re-filling our well on these levels is more about getting our needs met in these areas. Compassion fatigue can generate feelings of isolation, powerlessness and feeling overwhelmed.
Are we connecting with meaningful friendships to combat that isolation? Are we expressing ourselves creatively and feeling competent in other areas of our lives?
Are we consciously engaging in device-free time, in connection with the natural world, simplifying our lives?
Do we feel like we are truly in charge of our own lives?
When we come back to our own center and feel like our needs are getting met, when we feel safe and secure, energized and in balance, we can extend the heart of compassion to our clients and not fear intimacy. We can be the ally they need.
Michael Arloski, Ph.D., PCC, CWP, NBC-HWC – is a psychologist, coach, trainer, author and wellness enthusiast. CEO and Founder of Real Balance Global Wellness Services, Inc. (https://www.realbalance.com), his company has trained thousands of health and wellness coaches around the world.
Medical noncompliance is a vast and complex issue that results in widespread human suffering and immense healthcare costs. Of the 3.8 billion pharmaceutical prescriptions written each year (USA) it is estimated that more than 50% of them are taken incorrectly or not at all. Medical noncompliance also includes failure to do medical self-care, self-testing and attend follow up appointments with the treatment team.
As wellness and health coaches are given more opportunities to help people, especially people who have, or may soon develop, a chronic illness (heart disease, diabetes, cancer, arthritis, COPD, etc.), we will face again and again what has stymied healthcare professionals for decades; the patient who has heard the diagnosis but has made virtually no changes to improve their health. They have gotten the news but haven’t woken up and smelled the coffee.
The story is far too familiar. You may have seen it amongst the people you work with, your friends or in your own family. It may have been what you have experienced yourself. The person gets a new diagnosis of a life-threatening disease or is warned that such a disease is immanent (e.g. pre-diabetic) unless they make significant lifestyle changes. Or, perhaps they experience a sudden health event like a heart attack. Given medical treatment, they are also given a “lifestyle prescription”. They are told to make lifestyle changes: quit smoking; be more active and less sedentary; improve their diet; manage their stress better, etc. Such immediate lifestyle changes are conveyed as absolutely essential to their continued survival: a low-sodium diet for the hypertensive patient; lower stress levels for the post-heart attack patient; complete restructuring of the diet of the newly diagnosed diabetes patient, etc. Then, far too often, the healthcare professional watches, as do family and friends, in total astonishment, as the patient makes none of these changes. So, when lifestyle changes are necessary what determines a person’s ability to make the needed changes in the quickest way possible?
Readiness For Change
Working with clients around medical compliance and adherence to the lifestyle prescription is the place where Prochaska’s “Readiness for Change”, Elizabeth Kubler-Ross’s “Stages of Grief “, and Maslow’s “Hierarchy of Needs” all intersect. What we, the caregivers often fail to understand is that when a person has experienced a truly life changing event, like the onset or worsening of a health challenge they feel a loss of control that may threaten their safety, they experience grief at the loss of health, ability, or dreams, and often need to redefine their identity.
Pre-contemplation → Contemplation → Preparation → Action → Maintenance → Termination (Adoption)
This is certainly a helpful way to understand where someone is at regarding a particular behavioral change. Knowing if they are in the Contemplation or Preparation stage, for example, helps us know how to work with them. This single lens, however, is not enough. In the patient/client who astounds us with their level of non-adherence we find we are encountering more than just lower levels of readiness, we are encountering grief and loss.
Grief And Loss
A loss is a loss.The loss of a loved one through death, the loss of one’s health, or the loss of the dream held for how life would be, are all perceived as losses to be grieved. To help you understand a person’s reaction to a health challenge, diagnosis, etc., and to help you, as a coach or healthcare provider, respond more compassionately and effectively, put all of it in the perspective of the classic stages of grief. The work of Elizabeth Kubler-Ross, Stephen Levine and others have shown us that the grieving process is a multi-layered experience that affects us powerfully.
Kubler-Ross identified the five stages of grieving that are present for any significant loss: 1) Denial; 2) Anger; 3) Bargaining; 4) Depression; and 5) Acceptance.
I talk about this extensively in chapter ten (“Health and Medical Coaching- Coaching People With Health Challenges”) of my book, Wellness Coaching For Lasting Lifestyle Change, 2nd Ed., 2014 (https://www.amazon.com/Wellness-Coaching-Lasting-Lifestyle-Change/dp/1570253218/ref=sr_1_1?ie=UTF8&qid=1530811214&sr=8-1&keywords=arloski+wellness+coaching). When we see the astonishingly non-compliant patient/client, they are often experiencing this first stage of denial. They minimize the importance of the event, downplay its seriousness, and do all they can to return to “business as usual”. Talking about the event or diagnosis becomes a forbidden subject and the person may become quite defensive. They are angry that this tragedy has befallen them, and understandably depressed about what has happened, and the state they are in. The idea of change has no appeal and they often seek the comfort of the familiar — including self-soothing habits such as smoking, overeating, etc.
The experience of a “brush with death”, or even the news that such a threat is imminent, can automatically push us into survival mode. No matter what level we were at in getting our needs met on Abraham Maslow’s Hierarchy of Needs (see Chapter One – “Toward A Psychology of Wellness” in my book, Wellness Coaching For Lasting Lifestyle Change, 2nd Ed. 2014) such an experience necessarily drives us down to the survival need level. We feel profound threat to our “safety needs” and “physiological needs”. Our very physical existence is threatened. Life becomes about the real basics of survival; the next breath, food, water, shelter. It becomes about the basics of safety; feeling secure, going back to the familiar, whatever reassures us that we will be OK.
It is no wonder that people going through such an experience may embrace the status quo, resist change and psychologically minimize the threat that they perceive.
This brings up questions about the health challenged persons readiness to change:
* How long will they stay at these survival levels seeking to meet their physiological and safety needs when they are encumbered by the initial stages of grief?
* How effective can one be at functioning and rising up through both the stages of readiness for change and the lower levels of the needs on Maslow’s model if they are in denial and minimizing, acting out in an angry manner or shackled by depression?
What needs to be considered to work effectively with health challenged clients is the intersection of these three widely accepted psychological theories Once understood, a Wellness Professional can truly motivate their client towards lasting lifestyle change.
Maslow’s theory of motivation contends that as people get their needs met at the lower levels of the Hierarchy of Needs Triangle they naturally move on up to the higher levels (their being needs). When we encounter a patient/client who fits the picture we are talking about here, do we acknowledge where they are at and do we help them get their needs met at that level? Or, do we demand immediate behavioral change just because the value and urgency of it is so great?
Meet Them Where They Are At
Our first job is to help them feel like they have an ally, someone who supports them and has their best interests at heart. This helps meet their safety needs and even some of their social needs. We then need to check in with the person and see how they are doing at the survival level. Are they receiving the medical care they need? Is their living situation allowing them to cover the basics of shelter, food, and safety? Much of this comes down to how their health challenge affects the security of their way of making a living. How do they perceive (and it is their perception that counts) their health challenge as a threat to their livelihood? Do they fear losing their job, falling behind in production, having their business falter or fail? How much are they into catastrophic thinking about all of this?
What is more frightening than to believe we are powerless? The threat to our very survival is there, like a cave bear at the mouth of our cave, and we believe we can do nothing to stop it. If our patient/client feels powerless to affect the course of their illness, then they wonder why should they make all the effort required to achieve lifestyle improvements? When we feel powerless we often don’t go to fight or flight, we freeze.
The reflexive response to fear is contraction. Hearing a sudden, loud noise, we instantly tense up and contract all our major muscle groups. Feeling scared, we hold on. We reflexively hold on to what we have and to the way things are. Change seems even scarier than what frightened us to begin with. We are like the person in the path of a hurricane who won’t leave the safety of home, sweet home, even though it will probably be flooded and blown away. For our client to “let go” and trust in the change process their physiological and safety needs have to be met. If they doubt this they may give the appearance of compliance, but their probability of follow-through is questionable.
Beyond the very basics of survival, we can help our client then to get their needs in the next two levels met: Social Needs (sense of belonging, love) and Self-esteem Needs (self-esteem, self-worth, recognition, status). This is where coaching for connectedness plays a priceless role. We know that isolation is a real health risk and at this crucial time the presence and engagement of an extended support system can provide huge benefits. Our client will need the help of others in many practical ways, but they will fare far better if they are getting the emotional support that comes with getting their needs for belongingness, acceptance and compassion met. We, the helper can only provide a very small part of this and some of our best efforts may be to help the person we are working with to find, develop and expand sources of support in their lives. The nature of the support they receive from others is important as well. This person needs understanding, empathy and support, not criticism and pressure to make lots of changes immediately. We need to encourage our client to ask for the support they need in the ways that they need to receive it.
Coaching to improve self-esteem allows the client to move on up through Maslow’s triangle through the next level. We all need to feel good about ourselves, to receive recognition and praise. When one is hit with a health challenge they may feel anything but good about themselves. Perhaps they are framing the health event or onset of an illness as a personal failing. There may be embarrassment and/or shame that they are no longer completely healthy. Their own “inner-critic” may be very harsh on them, filling their mind with self-critical thoughts that, again, cause them to do anything but take action for change. Helping the person to regain a sense of power and control in their life can also reclaim self-esteem. When we feel powerless to control events and circumstances in our lives we feel weak, vulnerable and impotent. When we discover what we can actually do through our own lifestyle choices to affect the course of our illness for the better, we feel empowered and regain confidence and strength.
Ten Ways to Effectively Coach the Health Challenged.
When we encounter: the person who has had a heart attack and is still downplaying the importance of it, almost pretending that it didn’t happen; the person diagnosed as pre-diabetic who has made no dietary changes at all and remains as sedentary as ever; the person diagnosed with COPD who is still smoking, etc., we need to respond to them in a more coach-like way. In each step consider that their readiness for change will be determined in part by their stage of grief and where they fall in Maslow’s hierarchy of needs. How quickly they move through the change process will be in part determined by past experiences and in part by the support they have in the present to change.
1) Meet Them With Compassion Not Judgment.
Catch yourself quickly before you criticize their lack of adherence to the recommended lifestyle changes they have been told to do. Bite your tongue, so to speak, and instead of forcefully telling them what they should be doing, and warning them, once again, of the dire consequences of non-adherence, respond with sincere empathy and listen. 2) Acknowledge And Explore Their Experience.
Ask them what it was like when they found out about their health challenge; diagnosis, or what is was like when they experienced this health event. Don’t jump to solutions or start problem solving. Just listen, really listen. Reflect their feelings. Acknowledge what was and is real for them. Explore it with them and see if there isn’t some fear that needs to be talked about here. 3) Don’t Push, Stay Neutral In Your Own Agenda, And Explore More.
While it may feel like this person needs to take swift action with tremendous urgency, be patient. Readiness for change grows at a different rate for each step of the journey. 4) Be Their Ally.
Help them feel that they are not facing this alone. This helps meet their need for safety and even some of their social needs. Does the client understand their health challenge? To what degree does the client understand and buy into the lifestyle changes suggested? 5) Address Survival First.
Make sure they are getting all the medical help and information they need. Explore their fears about maintaining income, job, career, business, and how it all will be impacted by their health challenge. Help them gain a sense of control and feel more safe and secure in all ways. Help them to see that they are not completely helpless and vulnerable, but that there are ways they can affect their situation. 6) Help Them Process The Loss.
Talking through the grief is very powerful. The loss of health is felt to the level that it is perceived. That perception will be part reality and part fear. Help your patient/client to process their feelings, to give a voice to the part of them that is afraid. Accept their initial tendency to minimize but slowly help them feel safe enough to move through the other stages of grief (anger, bargaining, depression and finally, acceptance). 7) Help Them Form A Plan.
Even if it is very basic, help them develop a plan for becoming healthy and well again and how to face their health challenge. Meet them where they are currently remembering that preparing to take action is a vital readiness for change stage. What do they need to know? Having a plan will give them both hope and a sense of purpose and direction, a map to find their way out of their current situation. It is something to hold on to. 8) Coach For Connectedness.
If the basic survival needs feel met the person can reach out to others and will benefit from a sense of belonging. Family and friends need to be inclusive and not critical. Support from co-workers is also extremely helpful. The fear that is brought up by the onset of serious health problems sometimes frightens others and efforts need to be made to break through this initial resistance. Coach them through their own reluctance to asking for support. 9) Build Self-esteem.
Recognize, acknowledge and reinforce all progress. There is no wrong! Help your patient/client to exhibit greater self-efficacy because as they take charge of their health and their life, their self-esteem grows. 10) Nothing Succeeds Like Success.
Help the health-challenged person to take small steps to prepare for change and then experiment with actions where they are most ready. Build on these easier successes and leave the tougher challenges for later after confidence has been built.
Maslow reminds us that “growth forward customarily takes place in little steps, and each step forward is made possible by the feeling of being safe, of operating out into the unknown from a safe home port, of daring because retreat is possible.” (Toward A Psychology of Being, 1962) . To emerge from that home port, our client needs to be in the process of working through their grief, they need to be moving up the spiraling stages of change, and how better to set sail towards the unknown lands of change than with a good ally?
Michael Arloski, Ph.D., PCC, CWP, NBC-HWC
The first version of “Astonishing Noncompliance” was originally published in the Real Balance Global Wellness Services, Inc. Newsletter in 2009. It has also been published by a number of other organizations such as the American Holistic Nurses Association (https://ahha.org/selfhelp-articles/astonishing-non-compliance/)
Arloski, M. (2014) Wellness Coaching For Lasting Lifestyle Change, 2nd Ed. Duluth, MN: Whole Persons Associates.
Kubler-Ross, Elisabeth. (1997) On Death and Dying. NY, NY. Scribner.
Maslow, Abraham. (1962) Toward a Psychology of Being. Princeton, N.J., VanNostrand.
Prochaska, James, and Janice. (2016) Changing To Thrive. Hazelden Publishing.
Prochaska, J., Norcross, J, & Diclemente, C. (1994) Changing For Good. New York, NY: Harper Collins/Quill. 1994 Harper Collins, 2002 Quill reprint.
Our previous blog post: Getting Yourself Out Of The Way: The Self-Vigilant Coach – Part One (https://wp.me/pUi2y-mu) explored the many ways in which the coach can interfere in the coaching process and “get in the way” of the client’s own coaching work. Our own agendas, attitudes, beliefs, prejudices, projections and unfinished emotional business can all impede the coaching process. In this second part of the two-part series we’ll examine the complex concept of projection in coaching.
Another pitfall for the coach to be aware of is our tendency to project onto other people emotions that are really our own. A classic defense mechanism, psychological projection is when we attribute to others feelings of our own that we find unacceptable. The most common example is when we have unwanted feelings of anger and instead see hostile and aggressive qualities in the behavior and affect of others.
A broader understanding of projection, and a less pathological one, is that we project onto others not only negative qualities (anger, guilt, shame, etc.), but positive ones as well. These are positive qualities that we do not believe that we fully possess, but we ascribe them to the other person (successfulness, popularity, self-confidence, etc.). We can also include in projection the type of hopes, beliefs and dreams we have. We may want to believe that our client feels as passionately about exercise or meditating as we do! We may proceed with our coaching operating as though our client is fully on board with our wellness prescription for them. Conversely, as we have struggled for years with weight loss or smoking cessation, we project the same degree of difficulty onto our client’s experience, when, perhaps for them, that challenge is nowhere near as great. We fall into the trap of making assumptions, believing that other see the world just as we do.
We can also project our prejudices. If we come from a blue-collar working-class upbringing, we may think that our wealthy upper-class client has an easy life and knows little of heartache and struggle. We may withhold our empathy when it is really needed. We may completely underestimate the potential of our client because of their social status, gender, race or ethnicity and not treat them as being “naturally creative, resourceful and whole.” (http://www.coactive.com/learning-hub/fundamentals/res/FUN-Topics/FUN-The-Co-Active-Model.pdf)
If It Were Me…
A basic human tendency is to attempt to understand others by asking ourselves How would I feel/What would I do, if I was experiencing that? We put ourselves in their situation, and instead of going into a place of empathic understanding, we project our own feelings, conclusions, solutions onto the other person. We “know” what they ought to do! Perhaps our own work history includes supervisors who were bullies. Without realizing it we may hear our client’s story of conflict with their team leader and translate what we hear into a story of brutal abuse. We may then operate on the feelings this generates and steer the client towards taking extreme action to deal with a rather mild situation. For the client it was what we might call at one-dollar item, but we project a situation worth $100.00 plus change!
Our Own “Stuff”
Coaches may also project onto their clients the struggles and growth processes that they are currently engaged in and faced with. The coach who is exploring healing their own family of origin issues may see a need for this in many of the clients that they see. They may mistakenly think that the therapeutic process that is helping them so much is the panacea for all clients. They may start bleeding the techniques of their favorite self-help therapy book into the coaching that they do. The self-deception is that they may still think that they are doing coaching.
Perhaps the most disastrous type of interactions occurs when we project in such a way that we relate to another person as though they were someone else. Perhaps you’ve had this happen to you in your own life. Someone you’ve met recently keeps ascribing to you qualities that you exhibit very little of. They see you as self-centered, a braggart, trying to impress others, when all you did was share a couple of tidbits of what you knew about some subject. The problem is, you remind them of their brother, sister, ex-partner, former employer, second grade teacher, college roommate, army buddy, etc. who continually played the know-it-all role. Now all of the terrible qualities of that other person get projected onto you whether you deserve them or not!
Could the client who seems to bother us in ways that we find hard to explain be the unfortunate recipient of our projection? Do they remind us of someone else; a personal relationship from our past, or perhaps even a former client who struggled with the same issues? Do we begin coaching as though we expect this client to struggle the same way our other client did? Are we bringing our own unfinished emotional business into the coaching relationship?
When we are on the receiving end of our client’s projections, how do we handle it? A client who treats us as the high and mighty expert may cause us to overcompensate by being so informal and friendly that we now come across as a “buddy” or “pal” instead of a professional coach. The client who projects a parental role onto us may bring out our overly professional, even stiff and impersonal side. Such a client may become unexplainably resistant to even the best form of coaching accountability. The coach who is working with a client from a company who incentivizes employees to seek coaching to receive by promising a discount on health insurance, etc., may find their client unusually hostile. Such a client may be projecting their own issues around authority onto the innocent coach. The list goes on.
The central problem with our own projection is that it is operating outside of our awareness. We make our assumptions without even realizing them. We slip into feeling that we do know best for our client, and on and on. Let’s look at ways to minimize the occurrence of our projection.
• Coach with a sense of self-monitoring. Check in with your own affective and bodily sensations and determine what they are telling us. • Set clear boundaries and expectations for the coaching relationship as you create the coaching alliance. • Draw a clear distinction between coaching and therapy. This includes operating from a coaching mindset, not an analytical, diagnostic mindset in our relationship with our client. • Be vigilant for parental feelings that arise where you believe that you know what is best for your client • Reflect upon the client who brings out unusual feelings in you that are hard to explain or understand. Listen to recordings and examine your responses to your client. • When client reactions to coaching interactions seems extreme, consider what else might be going on that has nothing to do with the here-and-now coaching experience. Inquire gently “Does this remind you of any other experiences you’ve had?” “What’s this coaching like for you? Is it similar to anything else you’ve done?” • Seek out mentoring/supervision to explore puzzling client relationships that “don’t feel right”. • Do your own work! Your own personal journey of personal growth and healing may need some attention if it is leaking into your coaching work. Don’t let your own “unfinished business”, get in the way!
“I just don’t seem to have the motivation to really make changes.” This is a lament frequent to the ears of health and wellness coaches. Our clients are often puzzled by a lack of success in their efforts to start living a healthy lifestyle, or keep such efforts going. They blame it on either a lack of motivation to get started, or that their motivation fades as old habits reassert their rule.
Coaches help their clients examine and re-examine whatever sources of motivation they have mentioned. They help their clients revisit their desire to change and what drives it. They look at fear-based motivations such as not wanting to have an illness get worse, or not wanting to develop the maladies that have been prevalent in their family. They look at the love-based motivators like caring enough about ones self, wanting to be there for their grandchildren as they grow up, the intrinsic joy of dancing, swimming, tasting delicious and nutritious food, etc.
Perhaps the coach concludes, like their client, that these motivators just ‘aren’t enough’. The next step is to begin a usually fruitless search for additional motivators. Their client runs out of ideas and coaching descends into ‘what about this?’ suggestion after suggestion. What is really going on? What’s a more productive avenue to explore?
Your client may have enough motivation. They may in fact, have listed three, four or more reasons they want to change. They may possess a terrific combination of motivators. Motivation is like the fuel for a vehicle to run on. The problem might not be the fuel, but the lack of an actual vehicle! The vehicle is a methodology, a structure, and a process that facilitates change. To get where they need and want to go, the client needs both a vehicle to carry them and the fuel to put in it.
How do we mobilize motivation? By providing our client with methodology. I’ve always been amazed at how simple successful change can sometimes be when clients have a well-developed way of achieving it.
Coaches often hear their client’s frustration at wanting to improve their lifestyle, but not having much of a history of success at it. If we inquire if they have ever started their change efforts by first taking stock of their health and wellness in a really clear way, we find they rarely have. If we ask if they have ever begun by first developing a thorough plan as to how they will make their changes happen, we often find them admitting that they usually just get their will powered amped up and set some sort of goals. Rarely have they ever carried out their change efforts with the help of an ally who helped them with support and accountability. And, all too seldom have they ever keep track of their efforts at change and actually written it down.
A mentee of mine was recently coaching a middle-aged woman who complained of a lack of motivation holding her back. As we began listening to the recording, the coach helped the client describe at least four strong motivators that had propelled her into action. She realized that when her children were younger playing with them had provided her with more activity and energy. Now her energy was low and she wanted to reclaim that. She also talked about hoping for grandchildren and wanting to be a very active part of their lives. The client was concerned about her advancing age and not wanting to lose the health she had. She didn’t want to become a burden to anyone. She went on to list at least two more motivators.
As the client described her lack of success at change, her conclusion was that she was just lacking motivation. She described coming home from work tired and just fixing a quick (though not necessarily healthy) meal and watching television in the evening. “I just don’t have the motivation I need” the client lamented. She intended to be more active and intended to eat better. All she had for a plan were intentions.
Doing a great job of coaching, my mentee gently confronted his client and recited the substantial list of motivators that she did, in fact, have. He questioned whether it was a ‘lack of motivation’, or something else that was missing.
Clients try to figure out what is keeping them stuck. Unless it’s a matter of identifiable internal or external barriers, clients often say it’s a lack of motivation. They are looking for an explanation and, frankly, they often don’t know what else to call it.
Co-Creating The Coaching Alliance
An often ignored part of coaching is the work it takes to Co-Create The Coaching Alliance. In addition to getting acquainted with our client and hearing their story, an important part of our first session with a client is to convey to the client just how coaching works. Clients are used to meeting with consultants, not coaches. They expect to be able to provide the consultant with lots of great information and hear the expert recommendations. We spoke about this from the coach’s point of view in our last blog post: “Making and Maintaining The Shift To The Coaching Mindset”https://wp.me/pUi2y-m3. The client also needs to make a mindset shift to get oriented to this new way of working with someone.
Coaching is about co-creating agreements. We co-create with our client agreements about how we are going to work together. Some aspects of our working together are negotiable and can involve compromise. However, we are not going to compromise the nature of our coaching relationship. That is, we are not going to agree to just be our client’s educator, and let go of the role of coach.
Part of what an effective coach does is to explain, in a succinct fashion, exactly how coaching works, how it is structured and what the benefits of this structure are. The client-centered nature of coaching is conveyed with real reassurance that the client remains the one in the driver’s seat.
Part of the coach’s job is to facilitate the client’s use of the coaching structure. The coach does this by showing the client how advantageous it can be to operate with a solid plan, to track one’s progress at making changes, etc. The coach provides tools that make these processes easier. Mobile apps for tracking can be recommended and then, importantly, integrated into the coaching accountability.
Motivation can be puzzling and elusive, but when it is present a methodology, a structure, is what the client needs in order to mobilize it. By providing our client with the vehicle, we help them get where they want to go.
Word Origin – Coach: In the 15th Century the Hungarian village of KOCS was the birthplace of the true carriage or “coach” as the word evolved in English.
In other words we might define both types of coaches as: A coach takes you from where you are at, to where you want to be!
We meet our coaching client with the very best of intentions. We want to help. And help sometimes means throwing ourselves into doing what the client seems to be unable to do themselves up to this point – figure out solutions. Instead of empowering our clients to come to their own solutions, we seek to fix it for them. We draw upon our knowledge, our wisdom, our intelligence, and put effort into guiding the conversation to this goal of helping the client to live better and be healthier. We take on more than our share of responsibility for outcome. Perhaps we even let our own needs for control influence what is going on.
Your client is speaking about a very challenging situation in their complex life. You are fully engaged – in trying to figure it out. You sincerely want to help. You are curious, in a detective sort of way. Your internal chatter is racing: ‘What’s going on here?’ ‘How can the client handle this better?’ ‘What should the client do?’ ‘The client is not dealing with this effectively.’ ‘The client is engaging in self-defeating behavior or irrational thinking.’
So, you ask questions. Really good questions. You delve deeper into the problems. You seek solutions. You analyze. But, you’re not coaching. The more you think the less you feel. The more you analyze and use deduction, the more you step away from your client and all that they feel and all that they are. You, the coach, forget to empathize. You may even forget to use your Active Listening Skills, like paraphrasing and reflection of feeling. You forget to neutrally help your client explore and to do the work themselves. You have become your client’s consultant, taking on the work that belongs to your client.
As James Prochaska loves to say about change; making the “Mindset Shift” to the Coaching Mindset is a process, not an event. The shift did not happen that day when you completed a Wellness Coach Certification Course, and then become locked in place. We all keep going back to our default setting, be it treatment provider, educator, or consultant. What reinforces the old mindset is that many of our clients expect us to be the consultant, the trusted expert. They are used to working with consultants of every stripe and they often come to coaching with feeling of low self-efficacy and seek the guidance of experts who can point the way for them.
In Our Heads
The more we are in our own heads, the more we miss about what is going on for our client. Our analyzing and wondering about where to go next removes us from what is happening right here and right now. Perhaps our client is talking about what they had for breakfast, and the greater context is that they are having breakfast alone for the first time after their children have gone to live with their former spouse. We are missing the undercurrent in their voice of loneliness. We miss inquiring about their emotions, and, instead focus on the cholesterol content of what was on their plate. We miss reflecting our client’s feelings because we don’t notice what they were feeling. We miss an opportunity to express empathic understanding.
Trust The Coaching Process
To quit our consulting job and truly coach we must trust the coaching process. It is a leap of faith to let go of our urge to help and instead to assist. We have to trust not only the coaching process – that it is valid and potentially effective – but also trust our client. As The Coaches Training Institute http://www.coactive.com teaches, when we feel it “in our bones” that the client truly is “naturally creative, resourceful and whole” we can finally coach. When we apply this “Cornerstone of Coaching” we don’t rescue our client by finishing their sentence. We don’t provide for them what they may actually be capable of creating themselves.
Most importantly we don’t interfere in our client’s lives. Think about it! What right do we have to interfere in anyone’s life (and I’m referring to way of living, not intervening in an emergency, etc.)? Do our coaching “interventions” actually constitute an act of interference in how someone is choosing to live their life? Coaching is NOT an intervention!
Back To Center – Back To The Present
So, how do we stay in the moment with our client, yet provide the structure that is an absolutely essential part of effective coaching? It comes down to the proverbial “dancing in the moment” that coaches are so fond of referring to, but it also acknowledges that we have made an agreement with our client about the music.
An effective coach operates within an evidence-based, theoretically grounded coaching structure. We provide a methodology that allows facilitation of the client’s success at improving their lifestyle and therefore, their life. As we follow that “music” (our agreed upon coaching structure) we put our attention into the process of awareness. We listen with ears, eyes and heart. We pick up on the nuance of speech that reveals what may be going on beyond the surface. We explore without preconceived notions of what the client’s experience is. We may just simply say to the client we observe with the tight voice and the furrowed brow: “Are you aware of your forehead right now as you say that?” Let them do the work. Coach!