Astonishing Non-compliance – Understanding Grief and Readiness for Change in the Health Challenged Client

Coaching Can Help Medical Compliance

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.

We have long tried to understand people’s adherence to recommendations for lifestyle improvement through the lense of Prochaska’s Readiness For Change model (Changing For Good, 1994, Changing To Thrive, 2016 (https://www.amazon.com/Changing-Thrive-Overcome-Threats-Happiness/dp/1616496290/ref=sr_1_1?ie=UTF8&qid=1530810645&sr=8-1&keywords=changing+to+thrive+prochaska). This model, though primarily tested with addiction clients, revolutionized how we think about behavioral change in the healthcare world. James Prochaska and his colleagues reminded us that change is a process, not an event and that people change when they are ready to, not before. Furthermore, the change process is made up of six stages, not just ready or not-ready.

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.

 

Survival Level


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?

 

Dr. Michael Arloski

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/)

 

References
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.

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Real Balance GLOBAL – Taking Wellness Coaching To China

Taking Wellness Worldwide
Taking Wellness Worldwide

What The World Health Organization dubbed “Lifestyle Disease” is a global phenomenon. The increase of non-communicable disease is going up the fastest in what is sometimes called the developing countries of the world. “Twenty-five years ago, the number of people with diabetes in China was less than one percent. Today, China has more than 114 million people suffering from the disease, the highest number of any country in the world. It is estimated that 11.6 percent of Chinese adults have diabetes, a proportion higher than the U.S. with 11.3 percent. Experts blame the increase in sedentary lifestyles, high consumption of sugary and high-calorie Western diets, excessive smoking and lack of exercise.” (http://www.counterpunch.org/2015/07/24/the-increasing-burden-of-diabetes-in-china/)

From the very start of my work in developing the field of wellness coaching my vision was to bring wellness worldwide. Real Balance Global Wellness Services, Inc. (http://www.realbalance.com) has now trained over 6,000 health and wellness coaches around the globe. We have trainers in Ireland, Brazil and Australia. We have trained people from places like Dubai, Ethiopia, Hong Kong, Denmark, Korea, and many more countries through our fully-interactive webinar trainings.

shanghai0515-cityscapeNow we are continuing with our global mission by TAKING WELLNESS COACHING TO CHINA ! We are proud to announce that Real Balance is teaming up with Chestnut Global China EAP (http://chestnutglobalpartners.org) to bring wellness and health coach certification training to China! I will deliver a certification training in Shanghai March 14-19, and then travel on to Beijing to promote wellness coaching and do a book signing.

2nd Ed Cover - MedThe book I will be signing in Beijing is Wellness Coaching For Lasting Lifestyle Change, 2nd Ed., newly translated into Mandarin and published in China! The challenges of “lifestyle disease” are rapidly increasing in China as more people move to urban areas, diets change, smoking continues to increase, culture shifts and stress increases as well. Helping people gain access to allies that can help them succeed at lifestyle improvement is just as important here as anywhere else.

We are exploring other ways to connect with people around the world to contribute to the health of the planet and its people. Please be a part of creating Allies For A Healthy World.

broadmoorcolospringsBack In The U.S.A.

Please join us in beautiful Colorado Springs, at The Art & Science of Health Promotion Conference (https://www.healthpromotionconference.com).  March 27-31.
Real Balance will be exhibiting there and I will be delivering two workshops: “Five Key Coaching Skills For Motivating Sustainable Lifestyle Improvement”, and “Mastering The Science and Craft of Health & Wellness Coaching: Higher-Level Methods And Skills.” See you there!

The Health And Wellness Coach’s Value Proposition

Vp - overall image

Every potential coaching client is looking to have the question ‘What’s in it for me?’ answered. Every coach needs to be able to succinctly answer that question by conveying what they will provide for their client.

Potential coaching clients are rarely familiar with what a coach, especially a health & wellness coach, can do for them. They are used to dealing with educators and consultants, medical and otherwise, not coaches. Usually clients expect to be directed, educated, and led in the best direction for them. All too often they hear a wellness coach tell them something like:

persuade“I’m not going to tell you what to do. I’m not going to tell you what to eat or how to exercise. You’re the one in charge. You’re the one behind the steering wheel. You’ll be making your own wellness plan, and I’ll help you follow it.”

Why should this person become your client when it appears that they,
themselves, are going to be doing all the work?
Our client-centered approach to coaching does not mean we are not providing value, however we have to communicate the value of what we offer, and do it very clearly. What will the client gain from coaching?

This is true for the self-employed coach as well as the coach working for a wellness program, a disease management company, an insurance carrier, or any other organization that provides wellness and health coaching. It is about engagement. When coaches are confronted with the “incentivized” client, who is reluctantly complying with coaching in order to get their prize (or much-needed insurance discount), conveying the Health And Wellness Coach’s Value Proposition is more vital than ever.

Here is my way of presenting The Health And Wellness Coach’s Value Proposition. Please adapt to your own words and use it!

value-proposition

The Health And Wellness Coach’s Value Proposition*

Thank you for your interest in improving your lifestyle and your life. You may be new to coaching, and especially wellness coaching, so let me share with you the value that it brings.

Wellness/health coaching is all about you living the best life possible for you. To do that most people find there needs to be some improvements in their way of living, their lifestyle. Making those improvements, those changes is challenging when you have to do it all by yourself. Perhaps you’ve already had some experience with that.

When I work with someone in coaching I’m here to serve you. You are the one in charge of your life and our work together. It’s your hands on the steering wheel. I’m not going to tell you what to do and give you a pre-maid wellness plan. But, together we can co-create a plan to help you succeed at making the lifestyle improvements that you want to make.

As your coach I will be working with you to get very clear about where you are at with your health and well being right now. We’ll help you take stock of that by exploring together, using some coaching tools that will help give you a more complete picture, and by going over the lifestyle improvement recommendations you’ve gotten from treatment professionals. Then we’ll work together to help you form a clear picture of the kind of life you want to live, your healthiest life possible for you. We’ll compare where you’re at and where you want to be and together form a solid plan to help you get there.

Once we have that plan we’ll work together as allies to help you be accountable to yourself and follow through on the steps you need to be taking on a regular basis to help you achieve the goals you have in your plan. I’ll be with you throughout the journey. I’ll be there to help you strategize over, under, around and through the barriers that come up. I’ll help you with challenges that make it tough for you to live the healthy life you want and together we’ll help you keep on track. Together we’ll help you find and develop the sources of support that will make your changes last. We’ll evaluate our progress and adjust the course along the way as we need to. My goal is to assist you in becoming self-sufficient in your wellness, to be able to live a healthy life in a completely sustainable way.

I bring the value of a professional that knows about succeeding at lifestyle improvement. I bring the value of an ally.”

*(Created by Michael Arloski, Ph.D., PCC, CWP) Please adapt to your own words and use it!  If used intact you must include authorship credit and contact information (web address for Real Balance Global Wellness Services, Inc. https://www.realbalance.com)

Medium5

In two previous blog posts I shared some ideas about Market Development for the self-employed wellness coach. Please check them out for additional resources. The Self-employed Wellness Coach and Market Development – Part One: Closed Doors, Open Doors http://wp.me/pUi2y-9L The Self-employed Wellness Coach and Market Development – Part Two: Being So Much More. http://wp.me/pUi2y-bc

“Coaching for a Lifetime of Wellness: Five Keys to Sustainable Behavioral Change”

2nd Ed Cover - MedThe theme of the 41st Annual National Wellness Conference was “Spotlight On Sustainability”. While we often think about sustainability and our environmental practices, as a wellness coach and psychologist I immediately thought of sustainable behavioral change. As I prepared for my presentation on this topic my research revealed that we actually know very little about how effective our efforts at helping people improve their lifestyles actually are.

Maintaining success at lifestyle change is often daunting. Most wellness coaching clients have a history of initiating efforts at losing weight, stopping smoking, managing stress, etc. For many, however, there is a trail of failures at maintaining those new ways of living in the long run. The result is a lowering of self-efficacy and lingering feelings of discouragement. As I explored in a previous blog post “Lessons From Albert Bandura For Wellness Coaches” (http://wp.me/pUi2y-dB) there is much for coaches to learn about self-efficacy.

 When we go to trusted sources looking for help with making healthier behavior last, what do we find? Unfortunately, not much. From Harvard Medical School’s online publication Healthbeat I found “The Trick To Real And Lasting Lifestyle Changes”. (http://www.health.harvard.edu/healthbeat/the-trick-to-real-and-lasting-lifestyle-changes) Though this title sounds like the exact resource to look for, all it advised was a simplistic review of SMART Goals.

Turning to the APA Psychology Help Center we find “The key to making lasting lifestyle and behavioral changes: Is it will or skill?” (http://www.apa.org/helpcenter/lifestyle-behavior.aspx) This disappointing short article could only offer this: “Lasting lifestyle and behavior changes don’t happen overnight. Willpower is a learned skill, not an inherent trait. We all have the capacity to develop skills to make changes last,” said Katherine C. Nordal, PhD, executive director for professional practice at APA. “It is important to break down seemingly unattainable goals into manageable portions.” The article mostly talked about how ineffective we are at making any changes in our behavior and did not even address making changes last!

As I deepened my research quest I found that other behavioral scientists had been concerned enough about this issue to establish an impressive research consortium to tackle it. The result was a publication in The American Journal of Health Behavior (2010 Nov-Dec; 34(6): 647–659) entitled The Science of Sustaining Health Behavior Change: The Health Maintenance Consortium. The authors (Marcia G. Ory, PhD, MPH,1 Matthew Lee Smith, PhD, MPH, CHES, CPP,2 Nelda Mier, PhD,3 and Meghan M. Wernicke, MPH4) did a thorough research synthesis of articles spanning 2004-2009, amassed resources and funded twenty-one projects to look at this issue of lasting change in health behavior. Here is what they concluded.

elderly_hikingWhat we are up against when it comes to lasting change.

• How long can positive gains be sustained without additional long-term support?
• In most cases this is unknown because studies only track maintenance for a year or two after the post-intervention phase.
• In the majority of cases, intervention effects on lifestyle behaviors are often strongest in the one or two years closest to active intervention.
• Without additional support, positive effects tend to diminish over time, or treatment differences vanish.

What they found was frankly, not a lot.

• It’s not realistic to expect long-term maintenance based on initial interventions. (Single-variable research)
• Moderate-intensity behavioral interventions may need to be coupled with more environmental changes to sustain long-term effects.
• In other words people need the support of healthier communities and workplaces, peer groups, etc.
• Incorporation of physical activity into the self concept emerged as the strongest predictor, with self-efficacy having a major indirect influence confirming it as an important predictor for both behavioral initiation and maintenance

LongWindingRdIn summary:  The authors conclude that no single mediator makes a large impact; rather, there is a “long and winding road” with maintenance achieved through a multitude of modest interrelated meditational pathways from behavioral initiation to maintenance.

There are many reasons for our scarcity of knowledge. One is that much research of this nature is done by universities where graduate students need short-term projects that allow them to finish up and…graduate! We may learn more from larger sociological and epidemiological studies such as The Framingham Study (https://www.framinghamheartstudy.org) , the work of The Blue Zones, (https://www.bluezones.com) etc. However, here we are not isolating variables. We can’t really say if it was the plant-based diet, the supportive extended family, or the red wine that made the healthy difference. It seems we have to be satisfied with the shotgun approach and put our best bets on culture and environment.

What can we conclude about making positive changes in health and wellness behavior last?

• Changes must be sustainable over a lifetime
• Intrinsic motivation trumps extrinsic every time
• Most research looks at single interventions and doesn’t track more than one or two years
• Long-term studies show that a combination of environmental support and “internal” shifts sustain lifestyle improvement better. Culture, environment, attitude and beliefs!
• We must ask how can coaching support shifts towards “well” attitudes and beliefs?

Healthy Choices For A Lifetime
Healthy Choices For A Lifetime

The Five Keys of Coaching For A Lifetime of Wellness

• 1. Build Self-Efficacy
• 2. Nurture Visionary & Intrinsic Motivation
• 3. Focus On The Maintenance Stage (TTM)
• 4. Co-create Relapse Prevention Strategies
• 5. Coach For Connectedness

1. Build Self-Efficacy

Bandura’s Social Cognitive Theory (formerly AKA Social Learning Theory) shows tremendous congruity between it and the foundational principles of coaching. Bandura deeply explored the concept of Self-Efficacy which is foundational to wellness coaching. (Again see the previous blog post “Lessons From Albert Bandura For Wellness Coaches” (http://wp.me/pUi2y-dB)

2. Nurture Visionary & Intrinsic Motivationgreen nature_wood path

Much of our coaching work is around helping people to envision the outcome they want. When we have a clear picture of both where we are (our current state of wellness) and where we want to be (our Well Life Vision) we can “coach to the gap” between the two and coach around what needs to change to attain that Well Life Vision. Such a positive psychology approach is foundational to coaching and motivates better than just fear and illness avoidance.

We know that when clients experience intrinsic joy in activities they will be more motivated to engage in them. Look at the work of Jay Kimiecik, The Intrinsic Exerciser: Discovering the Joy of Exercise: ( https://www.amazon.com/Intrinsic-Exerciser-Discovering-Joy-Exercise/dp/061812490X) and Daniel Pink’s book Drive: The Surprising Truth About What Motivates Us (https://www.amazon.com/Drive-Surprising-Truth-About-Motivates-ebook/dp/B004P1JDJO/ref=sr_1_1?s=books&ie=UTF8&qid=1467763122&sr=1-1&keywords=Daniel+Pink+drive#nav-subnav).

To COACH for intrinsic motivation:
* Notice! – Help your clients to focus on the enjoyment, the pleasure that they perceive as they are performing the behavior.
* Inquire! – Ask about the details of their experience. When a client reports about taking a walk, hike or bike ride outdoors ask about what they saw, what they experienced, what they felt.
* Inquire about Bonus Benefits. Clients sometimes fixate on their goal of weight loss for example, but what else is happening during their efforts? Are they experiencing more energy? Better sleep? More mental concentration?
* Avoid incentivizing. Incentives tend to decrease intrinsic motivation.
* Take a Kai Zen Approach. (https://www.amazon.com/Small-Step-Change-Your-Life-ebook/dp/B00GU2RHCG/ref=sr_1_1?s=books&ie=UTF8&qid=1467763620&sr=1-1&keywords=robert+maurer#nav-subnav) Coach with your client to set up action steps that are so small that they are very doable and allow continuously successful progress towards their goals.

3. Focus On The Maintenance Stage (TTM)

Of all of the Stages of Change that Prochaska talks about in his Transtheoretical Model of Change (https://www.amazon.com/Changing-Good-Revolutionary-Overcoming-Positively-ebook/dp/B003GYEH2Y/ref=sr_1_1?s=books&ie=UTF8&qid=1467763816&sr=1-1&keywords=prochaska+changing+for+good#nav-subnav), coaching around the Maintenance Stage may be the most vital. Here the coach again takes a positive psychology approach and acknowledges and reinforces what is working. As the old saying from coaching goes “Nothing succeeds like success!” A key in this stage is for the client to see the value in Tracking Behavior and to do it regularly. Avoiding self-deception is key. Use whatever works for keeping track of new healthier behaviors: calendars, charts, apps, activity monitoring devices, etc. Then the Accountability that coaching provides makes the process conscious, deliberate and increases consistency. Lastly, coaches really prove their worth here as they coach their clients through the barriers and the “push-back” that sometimes is received by those who clients were hoping would provide support.

4. Co-create Relapse Prevention Strategies1369010631_url

Relapse happens! Count on it! James Prochaska is fond of back-up plans. We all know that life throws us curve-balls all the time. Our best-laid plans run up against life realities. This is where coaching can get creative! Coach clients to come up with their own back-up plans for then things don’t go as they would like, or when temptation increases. Going to a potluck dinner where the dietary direction of friends tends to be sabotaging of your wellness efforts? Be sure to bring an entrée to share that will satisfy your own needs. Not enough time to do your hour-long exercise routine? Having a quick and simple set of exercises you can do anywhere fills in “better than nothing” and maintains engagement in your program.

Pivotal to this key is self-compassion. There is a real difference between excuse-making and true compassionate understanding. Coach your client to be less self-critical and more forgiving. Help them keep a healthy perspective on their wellness plan.

5. Coach For Connectedness

Real Balance Faculty At The National Wellness Conference
Real Balance Faculty At The National Wellness Conference

In our Real Balance Wellness & Health Coach training (https://www.realbalance.com) we emphasize coaching for connectedness from day one. The amount of time any client spends in coaching is a brief moment compared to the lifetime they have to live in a new way. In addition to the support of the coach, other sources of support must be encouraged, discovered or consciously developed. For each step of action we ask “Who or what else can support you in this?” If our client has little support then making the development of such support a deliberate area of focus to work on in coaching is vital. This is where the role of culture, community, workplace, peer groups, family, friends, and relationships becomes a part of coaching that cements lasting lifestyle change.

Living a wellness lifestyle is a lifetime job! Providing the kind of coaching that goes beyond simplistic goal-setting and allows our clients to transform who they are can build the foundation for a lifetime of wellness.

A PDF of the PowerPoint from my presentation on this topic at The National Wellness Conference and a complete bibliography are available for download at: http://www.nationalwellness.org/page/2016NWCHando

If It Only Was That Simple: The Illusion Of Explanatory Depth

answersWhen faced with overwhelming, frightening and ultimately complex problems we tend to search for simplistic answers. Perhaps this is an adaptive attempt originating in the deep part of our brain known as the amygdala, where fear triggers our survival instincts (and our flight/fight/freeze response). In our ancestral days near our cave, taking action to freeze, run or fight like hell often served us well. Today, however we are faced with other stimuli that, despite our rationalizations and euphemisms to the contrary, actually do scare us just as much, but in a different way. No longer fleeing Saber-toothed Tigers, today, instead we face frightening foes like global climate change, racism, war and peace, extremist politics and chronic disease.

To combat these foes, we again seek the fastest, and therefore simplest responses that attempt to be solutions. Overly simplistic thinking causes us to latch on to attractive answers that seem to bring us some semblance of relief from the anxiety of overwhelm and the fear of the unknown. We generalize, minimize and seek solace in some quoted study that showed that ten people did one thing, one time, and now are healthy and safe for life. Eat low fat. Eat high fat. Don’t exercise…just drink wine! Chocolate could be one of your basic food groups!

“Psychological scientists have a name for this easy, automatic, simplistic thinking: the illusion of explanatory depth. We strongly believe that we understand complex matters, when in fact we are clueless, and these false and extreme beliefs shape our preferences, judgments and actions—including our votes.” (http://www.psychologicalscience.org/index.php/news/full-frontal-psychology/extremist-politics-debating-the-nuts-bolts.html)

Just diet & exercise...not so simple.
Just diet & exercise…not so simple.

In healthcare and wellness we take something as supremely complex as weight management and leave our critical thinking hats off as we search for some magical Thor’s Hammer that will strike down obesity, diabetes and heart disease with one swift (and don’t forget easy) blow. If it only was that simple!

As a University Counseling Center Psychologist I worked with a great number of victims of rape and abuse. I observed how victims would astonishingly blame themselves and go through a time of attempting to feel safer by saying “If only I hadn’t been in that place at that time”, or “If only I had been doing this instead of that”. The health and wellness equivalent may be when we seek out lifestyle practices that we hope will insulate us from disease and misfortune. I’m not talking about basic health-risk reduction here, but rather the way people grab on to simple all-or-none thinking about diet, exercise, stress management practices, etc. We think that kale, mindfulness, Yoga, coconut oil, or a new Fitbit will be our single-track savior. We want the comfort of the “illusion of explanatory depth”.

Everyday, when we look harder at the research, and that means going back to what we learned in Psychology or Sociology 101 about basic research, we can sift through all of the contradictory data and at least conclude that there is nothing simple about wellness, health and especially challenges like healthy weight management. In this internet-based age we are continually bombarded with headlines sprung from single studies with incredibly small “n’s”. Changing what we eat based on the success of seventeen people who dined while standing on one leg how we are urged to take action by headline-grabbing authors.

We all know how hard it is to get rid of cockroaches once they infest a place. Research publicity sometimes creates myths that persist just as tenaciously. In a brilliant recent blog (https://www.linkedin.com/pulse/beware-cockroach-effect-faulty-data-die-jon-robison?trk=hp-feed-artic) Jon Robison gives us more evidence about not trusting sketchy “evidence”.s-l300

The Cockroach Effect is certainly not limited to weight-related research. Dr. John Ioannidis has spent his career exposing the personal biases, economic pressures and downright bad science that plague medical research. In a seminal paper in PLoS Medicine in 2005 with the intriguing title, “Why Most Published Research Findings Are False,” he presented a model which predicted correctly that 80% of non-randomized studies, 25% of randomized trials and 10% of large randomized trials were refuted by later research. While we expect contradictions as part of science, Ioannidis also found that even when faulty research was debunked, its conclusions typically persisted for years or even decades. The details of his fascinating findings are explored in an article entitled “Lies, Damned Lies and Medical Science” which appeared in the Atlantic Magazine in November 2010.”

As tempting as it is to look for quick relief in simplistic answers, we must take a deep breath and know that health and wellness is a marathon, not a sprint. The progress may be found in a combination of studying both how we change, and how we maintain change.

This June at The National Wellness Conference (http://www.nationalwellness.org/?page=NWC2016) one of the breakout sessions I will be presenting is Coaching for a Lifetime of Wellness: Integrating the Keys to Sustainable Behavioral Change. We’ll look at how to shift our thinking from short-term outcomes to the only kind of study that really counts – the longitudinal study of one’s lifetime. There is a lot to explore about how to help people make lifestyle improvements that will have to last for the entire rest of their lives. The problems we face are multi-causal. The answers we seek need to be holistic and thorough. As many of you have heard me say “I did not write a book entitled “Wellness Coaching For Temporary Lifestyle Change.” See you in St. Paul, Minnesota this June!

Be well! Coach MichaelM-ConamaraDiamond1

 

 

The first rule of sustainability is to align with natural forces, or at least not try to defy them. Paul Hawken

A Thousand Pots of Brown Rice: A Mindful Way To Be Well

A Thousand Pots of Brown Rice
A Thousand Pots of Brown Rice

We all want to be as healthy as we can be, and are usually anxious to get there quickly, like it was a destination we could actually arrive at. Mastering a wellness lifestyle is rather like mastering any art, craft or skill. It’s more of a journey than a destination. Lifestyle means a way of living, and doing it well requires enjoying the journey.

The world around us sells the quick-fix. Becoming fit is presented as a dynamic and exciting adventure. Health foods are presented as not just nutritious, but delicious, exotic, fun and intriguing. The images of “well people” in the media portray beautiful individuals at their peak of physical fitness, exuberance and youth. The weight-loss marketing world attempts to entice us with programs that promise to be both exhilarating and expeditious.

For people who make real progress at improving their health, the reality is that change is slow, methodical, repetitious, and often plagued by lengthy plateaus. The folks who lose weight, get in shape, maintain good health and make it last are those who discover the secret of finding intrinsic reward in the mundane.


A Thousand Pots Of Brown Rice

masteryBkCoverIn his classic book Mastery: The Keys to Success and Long-Term Fulfillment (available online for free at https://www.thecorporaterookie.com/wp-content/uploads/2014/03/Mastery.pdf ) George Leonard describes the path to mastery as one of short bursts of increased performance followed by slowly ascending plateaus.

 

mastery curve better

Practice, practice, practice. The key is to learn to enjoy the plateaus and know that eventually there will be progress. We live most of our life in these plateaus. Losing weight, smoking cessation, and other efforts are fraught with plateaus. Brown rice! Again? Great musicians, golfers, Yogis, all learn to love the practice. Living a wellness lifestyle is really practicing a way of living…over and over again. To keep it alive we have to notice. Noticing – being aware and mindful of the here and now – allows us to discover intrinsic joy through our senses and our emotions. There is great sensory satisfaction in the taste and smell of well-prepared wholesome food. There is real joy in the act of movement waiting to be discovered. There is true emotional satisfaction when we effectively execute a lift, a dance move, or leap over a small stream on a hike. The key is to notice.

Fortunately brown rice does taste good, kind of plain, but good. We can always spice up the brown rice in our life. Throw in a little cumin, some sort of variation to liven things up. Think of how this applies to a workout routine, a new route for that noon-time dog walk, or nurturing a new friendship to bloom instead of just sticking to our usual crowd. This helps, but what gets us through 365 days in a year, is enjoying our practice, simple as it is, of living a well-life.

Five Keys To Mastery

In Mastery, Leonard describes five keys to mastering anything, be it music, tennis, computer programming, or, in our case, living an outstandingly well life. He points to: 1) Instruction; 2) Practice; 3)Surrender; 4) Intentionality; and 5) Pushing The Edge. Here’s how this applies to our quest for mastering a wellness lifestyle.

1. Instruction

older-woman dumbells
In a world of infinite choices about what to eat, how to exercise, meditate, etc., the challenge is to separate the whole-wheat from the chaff. This is where we need to do our due diligence on the sources of our wellness information. Part of what Leonard is referring to as Instruction, means finding valid and reliable sources for health information that don’t have a commercial interest in persuading us to see and buy things their way. It may mean seeking out real expertise appropriate for our needs. A certified diabetic educator will do a better job helping you set an effective self-management course than just looking things up online. A fitness trainer with solid professional credentials can help you find ways to strength train that will keep you at it for life because you’ll learn how to do it right from the start. A professional nutritionist or registered dietician can help you far more than your friend, or nearby clinic that wants to sell you all kinds of dietary supplements.

2. Practice

Wynton Marsalis
Wynton Marsalis

One can approach practice with either a mindset of The Imperative, or The Volitional. As a junior high school student I approached my trumpet lessons under the imperative mindset. I avoided practicing all week and then a night or two before my lesson I would get in a couple of 20-30 min. practices starting with those boring scales and exercises. I did want to be in the high school band, my parents had bought this shiny trumpet for me and were paying for the lessons, so… As I got older, I found that I enjoyed the sense of accomplishment as I mastered my lessons and could play tunes I relished. Playing in the actual band and especially the jazz band, was straight-up fun and spurred me on. Today whenever I think of a professional musician, like trumpet-master and bandleader, Wynton Marsalis, I think of the thousands of hours of practice that got him to where he is today. Think of a famous martial artist, the Bruce Lee type. How many times did they do their repetitious katas to get to where they could draw upon any move in a nano-second and execute it perfectly? To get there, at some point they practiced because they wanted to – the volitional.

The wellness lifestyle that is lived with a volitional mindset is one of choice and preference. We eat well because we have gotten to the point of preferring to eat that way by finding the intrinsic reward in doing so. Yes, we may be enjoying the added benefit of reducing some key dietary health risks, but what motivates our choices is pleasure and preference. We have discovered that healthy food can taste good! We walk, bike, lift weights, practice Tai Chi or Yoga, or both, because we truly enjoy such practices. We will do our best to prioritize the time to do activities we enjoy on a regular basis.

When we operate out of the imperative wellness mindset we choose the grilled chicken salad at the restaurant because we “know” it’s good for us. We may still crave the juicy hamburger and fries, but we twist our own mental arm and “do the right thing.” The imperative mindset around exercise is very self-defeating. We can easily maintain our “I hate exercise” mindset while doing what we are “supposed” to do. It will take less of a barrier to provide an excuse to skip today. The health-risk reduction approach to motivating us to be well actually counts on us employing the imperative wellness mindset. After all, it’s imperative that we do these things in order to be avoid illness!

We often start our wellness efforts with the imperative mindset. That’s fine. Until we achieve a bit of conditioning even walking can be tiring, or strength training can make us sore. My quads were screaming after my first Tai Chi lesson! Eating brown rice is not very thrilling to begin with. Also, fear may push us towards the imperative. Borderline cholesterol or blood sugar levels can scare us into action and get us started! For the changes to be sustainable, we want to work our way towards the volitional wellness mindset where practice becomes our new way of life, and we love it.

3. Surrenderfool

The path to being well doesn’t have to be boring. When we surrender to trying new things, to allowing ourselves to perhaps even appear foolish, we often discover rich rewards. Overcoming our initial fear and getting out on the dance floor, trying a food we can’t pronounce at first try, allowing ourselves to ask for support can open amazing doors.

Surrendering is not giving up. Here we are talking about surrendering our ego, our persona. What unnecessary limitations do we put on ourselves that hold us back from new opportunities? Do we really need to avoid vegetarian dishes in order to maintain some kind of image we have of ourselves? Can we try something that seems foreign to our own culture? This is where the word “try” has a positive spin. Instead of referring to a half-hearted effort, here we mean trying something like trying on a new pair of shoes to see if they fit. Think of all the pleasing surprises that have awakened new interests, new skills, new tastes, and new opportunities in your life.

4. Intentionality Das Ziel anvisieren

The way forward in living our lives better works best when we do it with full intentionality. Envisioning our best life possible and lying out a concrete plan to get there works much better than just mustering will power. Seeing us living our well-life vision can provide a motivational tipping point that pulls us towards practicing all of the day-after-day, mundane steps that make up a wellness lifestyle. We choose the healthier food option, or to get up and move not because we want to lose forty pounds, but because we want to live the kind of life we will have when we’ve lost those forty pounds!

Mind games? Yes, but better to engage in positive and purposeful mind games, than to slip into the negative mind games of self-deception and stuckness. Setting our intentions positively is a proven process that leads to success. Creating a well-life vision that motivates and then creating an actual Wellness Plan to get there gives us a road map for achieving the life we truly desire. These are the basic tools at the heart of all effective wellness coaching.

5. Pushing The Edge

comfortzonestretch

Finally, pushing the edge means extending our efforts just a bit further than we thought we could at first. It means walking in the rain anyway, sacrificing an old pattern to adopt a healthier one, taking a step that is safe, but for us very bold.

The key here may be distinction. Life in our “comfort zone” may be living up to its name, but as one quote goes, “nothing grows there.” Think about most of what you’ve achieved in your lifetime and your reflections will show that at some point success required vacating your comfort zone. We want to move into what is for us a stretch. It may be doing 15 chest presses instead of our usual 12. It may be allowing us to dance until the band goes home! The challenge is distinguishing between a “stretch” and a “risk” or even a “danger”. Sometimes a well-considered risk pays off. The new person we met agrees to get together socially. Perhaps we get out on the dance floor and no one really stares at us after all.

The 1000 Pots Of Brown Rice Approach cautions patience. At middle-age, if you go from never running to pushing yourself to run mile after mile, day after day, in less than a week you will probably have the painful condition called shin splints, or some other injury. Jumping on a radical, unproven diet craze may upset your metabolism, digestion, or worse. You’ve gone beyond risk into the danger zone.

When we are firmly on our wellness journey and have both a well-life vision and intrinsic motivation working for us, we push through more barriers. Suddenly going out on a walk in foul weather becomes a mere exercise in selecting the appropriate clothing. We tolerate a growling stomach a while longer in order to cook a healthy meal instead of capitulating to the expediency of an unhealthy pre-packaged meal. We take the “risk” of rejection by trying out a new social group of some kind. We get more “comfortable” with “stretching”!

Dr. Michael Arloski
Dr. Michael Arloski

The Coach’s Takeaway

In my next blog I’ll share what it takes to develop Mastery of Wellness Coaching, but for now let’s look at how the content above can help us coach our wellness clients more effectively.

1. Go for sustainability. To coach our clients towards lasting lifestyle improvement the changes have to be sustainable. Sustainability requires both motivation and access or ease of maintenance. Our client will be performing these healthy lifestyle behaviors for the rest of their entire life.
2. Motivation sustains. Embrace imperative, fear-based motivation for the value it brings, but coach towards the embrace of intrinsic motivation. Help your clients develop the skills of mindfulness around their wellness activities. For example, ask for them to describe in detail their experience of a recent walk. Where did they go? What did they see and notice? How did they feel through their senses – warmth of the sun, gentle wind on the face, etc.? Help them reconnect with the positive feelings of performing the wellness behavior. Coach for the co-creation of a Well-Life Vision that provides a motivational link between what they want the behaviors (day-to-day) to get there.
3. Move from the Imperative to the Volitional. Coaching’s client-centered approach helps people to realize that they are in charge of their own wellness. All the aspects of their Wellness Plan are of their own choosing. We are empowering individuals to achieve what they want for their lives. As we coach clients who are still stuck in the blame game, we need to ask them “How’s that working for you?” Helping them leave victimhood behind is a great step. As client’s begin their wellness journey because they feel they “should” (the imperative) we can support them in practicing their wellness activities and action steps that help them get to the point of better physical and emotional/psychological conditioning. Then they are more ready to experience the more positive, intrinsic rewards in the same activities that took so much effort before. Maximizing on that motivation makes the shift to the Volitional Wellness Mindset.
4. Reassure. Clients need support and reassurance that life on the mundane plateaus will finally lead to success. Coach them with your own support and coach for connectedness. Growing other sources of support in their relationships, families, workplaces, etc. are key to lasting lifestyle change.

Leonard likes to say that most of a Master’s life is living in the plateaus. Make them enjoyable ones

The Bigger Mindset Shift: Waking Up To Lasting Lifestyle Improvement

Wake up to a whole new way forward!
Wake up to a whole new way forward!

Just back from a whirlwind of professional travel, I’m struck by a pervasive awakening that our health is largely behavioral, and if we truly want to improve health worldwide, we must seek methods that support success at lasting lifestyle improvement. At the Lifestyle Medicine 2015 Conference http://lifestylemedicine2015.org, where I presented, we saw that the medical profession is embracing wellness & health coaching as never before. In Europe we witnessed increasing interest in how to integrate wellness coaching into health systems and medical training. In the large disease management company where I just delivered a week of training, there is truly a mindset shift from a consultant style of helping relationship using simple goal-setting to an integrative model based on the Real Balance Wellness Mapping 360°™ Methodology https://www.realbalance.com.

Real Balance Wellness & Health Coach Certification Training is continually fostering “making the mindset shift” – going from “prescribe & treat” or “educate and implore” to the coaching mindset of “advocate and inspire”. We repeatedly emphasize the importance of shifting from the Consultant role to that of a true Coach. The recognition that assisting people in succeeding in behavioral change is a very different process than sharing medical, educative or other expertise, is starting to take hold stronger than ever.

Making The Mindset Shift is our way of saying Wake Up and realize that co-creating wellness is the way forward.nature-landscape-path-walkway-mist-mountain-grass-sunrise-river-clouds-water-1920x1200

A co-creative way of working with people honors their inner wisdom, acknowledges the contextual factors that facilitate or inhibit lifestyle improvement while honoring and celebrating differences. Co-creation allows a person to be the expert in their own life, and yet does not send them out to climb the mountain alone. It is our commitment to accompany them on the journey providing support, guidance, tools, and our expertise in changing lifestyle behavior.

It is easy to feel overwhelmed by the increasing “lifestyle disease” health statistics documented by the World Health Organization. As we see budgets (whether of families, states, provinces, companies or countries) plundered by chronic illness expenses we are also, finally pulling ourselves out of the floodwaters, reaching for higher ground, gaining perspective, and seeing that more of the same will just continue to drown us. There is a coalition of Wellness & Health Coaching, Wellness & Health Promotion, Lifestyle Medicine and other like-minded people with enough vision to see that lifestyle improvement, individually and collectively, will be what allows us to keep our heads above water, start to swim and return to the healthy place that seems like dry land. Please join us!

“Let’s get together and feel all right.”
One Love
By Bob Marley

Michael & Deborah Arloski in London
Michael & Deborah Arloski in London