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 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

Delivering The Behavioral Side Of Lifestyle Medicine Through Wellness Coaching

Wellness Coaching: Bringing Light To Lifestyle Medicine
Wellness Coaching: Bringing Light To Lifestyle Medicine

“If we could give every individual the right amount of nourishment and exercise, not too little and not too much, we would have found the safest way to health.”
Hippocrates 420 B.C – 370 B.C.

Healthcare providers have been prescribing lifestyle improvement for thousands of years. The evidence has been built from the observations of Hippocrates all the way to the neuroscience of today. We know, from mountainous reams of data, that lifestyle affects the course of an illness or health challenge. The challenge for the healthcare provider of today is to see the “lifestyle prescription” translated into lasting lifestyle change. Many well-intentioned healthcare professionals have attempted to educate and admonish their patients into losing weight, ceasing the use of tobacco, managing their stress better, getting more sleep, being medically compliant/adherent, etc. Seeing actual success in behavioral change happening far too seldom, many have abandoned such efforts and just reach for the pharmaceutical prescription pad.

In recent years, however, there has been an exciting movement in the field of medicine that looks at how to use “lifestyle interventions” as first-line treatment.

“Recent clinical research provides a strong evidential basis for the preferential use of lifestyle interventions as first-line therapy. This research is moving lifestyle from prevention only to include treatment–from an intervention used to prevent disease to an intervention used to treat disease.”
The American College Of Lifestyle Medicine

The Lifestyle Medicine Movement has done much to establish an evidence base and it continues to examine research that distinguishes what appears to work for lifestyle improvement. Much of its attention has focused on nutrition, but more and more the field is realizing the importance of health and lifestyle behavior.

Wellness and health coaching has become the delivery mechanism for wellness programs, and its potential for the same vital role is being seen in Lifestyle Medicine. The reality is that the vast majority of clients that most wellness/health coaches see are already health-challenged in some way. They may already have a chronic lifestyle-related illness, or multiple risk factors that set them up for needing serious preventative help. Wellness/health coaches that work for disease management companies, insurance companies and many corporate wellness programs are already working with caseloads populated primarily by lifestyle medicine patients.

Lifestyle Medicine 2015
Lifestyle Medicine 2015

At Lifestyle Medicine 2014 (the annual conference of the American College of Lifestyle Medicine http://www.lifestylemedicine.org) I presented on “Wellness Coaching And Lifestyle Medicine: Covering The Whole Continuum”. This year I presented “Delivering The Behavioral Side Of Lifestyle Medicine: Wellness Coaching Skills & Concepts” at Lifestyle Medicine 2015 in Nashville. Together with other presenters on wellness coaching we have experienced a strong positive response from an audience made up primarily of physicians.

 

One of the key concepts of my talk that was especially well received was the idea of how the Treatment Plan needs to be integrated with the Wellness Plan.
TP-WP

Co-creating a Wellness Plan with our clients is one of the primary tasks for the wellness coach. Together we work with a structure that insures the client’s plan for lifestyle improvement will lead to success. A key part of that Wellness Plan will always be the “Lifestyle Prescription” that the client’s treatment team is recommending. What is key is that the Wellness Plan supports The Treatment Plan.

I will be talking further about this concept in my forthcoming book on the more advanced skills and methods of wellness coaching, but here is a sketch of the two plans and the way they overlap.

Treatment Plan
• Diagnostically Derived
• Treatment Provider Devised
• Prescriptive
• Responsibility on Provider to administer, responsibility on client to follow
• Usually does not accommodate patient’s circumstances or abilities, may accommodate patient’s capacities.
• Problem solving, solution finding oriented
• Purposed for resolution of illness and disease, reduction of symptoms, healing
• “Lifestyle Prescription” focuses on recommended behavioral changes leading to Lifestyle Medicine outcomes
• Dependent greatly upon medical compliance/adherence

Wellness Plan
• Derived through exploration and self-assessment combined with treatment recommendations.
• Co-created by “client” and “coach”
• Non-prescriptive – client centered
• Responsibility on client to follow with coach’s accountability and support
• Not only accommodates, but is derived from client’s circumstances, abilities and capacities.
• Designed to eliminate barriers and develop additional support
• Possibility, growth and self-actualization oriented.
• Purposed for behavioral change and lifestyle improvement
• Includes assisting client with medical compliance/adherence

Overlap Of Treatment And Wellness Plans

• The Wellness Plan (WP) supports the Treatment Plan (TP)
• TP identifies critical areas for recommended lifestyle improvement
• Through “client-centered communication” WP aligns with the goals of the TP
• Client engages, with coaching support, in lifestyle improvement behaviors that positively affect treatment outcomes
• WP helps client with organization, accountability, etc., improving attendance for medical appointments and management of medications, self-testing/self-care
• WP helps client make best us of medical appointments (self-advocacy)
• WP helps client report more accurately to treatment team about changes in lifestyle behavior (providing more data for treatment decisions)

so_healthcoaching_1When clients are operating on a Wellness Plan that they have truly helped co-create with their own buy-in, the opportunity for weaving in Areas of Focus, Goals and Action Steps that support what their treatment team wants to see becomes obvious. Clients then have the structure and support they need to carry out the goals of the Lifestyle Prescription.

Physicians and other healthcare providers can already start making use of wellness and health coaching as a delivery mechanism for the behavioral change they would love to see. Many of their patients already have wellness coaching as an employee benefit. Their company’s wellness program may already provide it, or they may contract with a wellness coaching provider company. More and more employees have wellness/health coaching available through their insurance provider.

© Copyright 2011 CorbisCorporationWise medical organizations and practices are hiring wellness coaches to become part of their staff or are outsourcing to them. Healthcare providers are sometime “wearing two hats” and combining their treatment work with coaching. Others are becoming more “coach-like” in their interactions and are then handing the patient off to the wellness coach for the longer process of lifestyle improvement.

The Real Balance Wellness & Health Coach Certification curriculum (http://www.realbalance.com) has included how coaches fit into the Lifestyle Medicine approach for over a decade. Our students come to us as a resource for learning how they can help deliver the lifestyle improvement that their Lifestyle Medicine clients seek.

Wellness Coaching to support Lifestyle Medicine is not just an idea whose time has come, it has already arrived!

Michael Arloski, Ph.D., PCC., CWPMedium5

 

Yes, We ARE Getting Healthier!

How Does Your State Rank?
How Does Your State Rank?

In the midst of the healthcare crisis, America’s actual health, in many ways, is improving! It’s easy to feel discouraged by the political struggles, obesity and diabetes “epidemics”. Hearing that the U.S. has a worse life expectancy than Slovenia and Chile is very disheartening. Yet, despite some huge challenges that aren’t going away, there is an upside.

The 2013 Annual Report by America’s Health Rankings® is in and the word is better than we may have expected. The longest running annual assessment of the nation’s health on a state-by-state basis, America’s Health Rankings has spent 24 years assembling health data to help us see our progress and challenges. (http://www.americashealthrankings.org)

The almost twenty-five year trend of increasing obesity appears to have leveled off since 2012. The scientists aren’t ready to predict which way the scales will tip on this one, but at least it’s not another increase. In 1990 almost thirty percent of Americans smoked. In the last year we finally edged just under twenty percent with seventeen states showing a decrease in smoking.

Healthier Hearts

Healthier Lifestyles, Healthier Hearts
Healthier Lifestyles, Healthier Hearts

A real eye-opener is learning that cardiovascular deaths have declined 36 percent since 1990 and each year continues to see a 2-3 percent decrease. We’re also doing a better job of helping people avoid ending up in the hospital when it could have been prevented. “Preventable hospitalizations continue to decline. In 2001, there were 82.5 discharges per 1,000 Medicare enrollees; in 2013, there were 64.9 discharges per 1,000 Medicare enrollees.”

The American workplace is also becoming safer. “Occupational fatalities have declined slightly in the last 6 years from 5.3 deaths in 2007 to 3.8 deaths per 100,000 workers in the 2013 Edition. Rates have reached a 23 year low.”

Though most of the decline happened between 1990 and 1999, infant mortality is 39 percent less than it was in 1990. Though not dropping much recently, there has been no increase in recent years. At the same time though, the number of children living in poverty continues to increase with the 2013 report telling us that slightly more than one in five American children live below the poverty line.

As you look at the state-by-state maps in the report the geographic and other disparities are painfully obvious. A close to home example show us this. “The prevalence of physical inactivity varies from a high of 52.8 percent of adults aged 25 and older who did not graduate high school in Arkansas to a low of 6.7 percent of college graduates aged 25 and older in Colorado.”

While challenges remain and stats like those found in the America’s Health Rankings report can help drive the changes we will need to improve our country’s health, the progress needs to be hailed. The knowledge that we can and in fact are being successful in improving the health of populations helps empower us all. When we see that a state like Nevada can lead the nation in decreased smoking there’s motivation to do more in our own neck of the woods!

Dr. Arloski
Dr. Arloski

The Coach’s Take Away

Many wellness coaching clients are discouraged not only by their own failure experiences, but also by the never-ending barrage of negative press that spotlights one problem after another. While a head-in-the-sand approach to life only leads to more problems, and we do need to increase our vigilance about the food we eat, etc., everyone needs to know that our country-wide wellness efforts are paying off. We talk about the client’s “self-efficacy”; their degree of belief that it is possible to positively affect their own health. Stats like America’s Health Rankings can show that there is reason to increase our collective sense of health & wellness efficacy. Positive psychology works!

Wellness Is About The Big Picture!
Wellness Is About The Big Picture!

Coaches also need to be involved in wellness beyond the one-on-one or small group work that they do. In a company, the key to a successful wellness coaching program is for it to be part of a larger comprehensive wellness program. Such programs provide not only coaching, but education, wellness skill building, opportunities to be well (healthier food access, physical fitness access, built-in movement throughout the day, etc.), and a thorough effort at establishing a culture of wellness throughout the organization at all levels. The natural extension of all of this is community and environmental wellness. Demonstrated progress can show decision makers in both industry and government that wellness works, and most importantly, is worth funding. Coaches who care about wellness can benefit by caring about the bigger picture as well.

Forging A New Wellness Path: Leaving Health Risk Reduction Behind

It's time to cut a new trail...innovate wellness!
It’s time to cut a new trail…innovate wellness!

Attending Lifestyle Medicine 2013 (http://lifestylemedicine.org/lifestylemedicine2013) in the Washington, D.C. area this week I was heartened to be around so many enthusiastic people from the medical world who have embraced the realization of just how behavioral health is. The conference was “small but mighty” and had doubled in size since the previous year.

Dean Ornish (http://www.ornishspectrum.com) spoke for two riveting hours. While he started out with the obligatory review of his professional research on the reversal of heart disease, etc., his last hour was spent focusing almost entirely on how the really key ingredients in health are social support, connectedness, and a person’s spiritual connection or meaning in life.

Dr. Dee Edington
Dr. Dee Edington

We heard from some of the real innovators and leaders in the field like David Katz, Caldwll Esselton, James McDougal and others. Someone on the schedule that I was really looking forward to hearing was Dee Edington  (http://www.edingtonassociates.com/index/aboutus)  It would not be exaggerating to call him the “Godfather Of The HRA” (health risk assessment). His thirty-five years at the University of Michigan Health Management Research Center (http://www.hmrc.umich.edu) forged much of what we know today about health risk assessment and the tons of data that came from researching this field. As wellness programs developed during the 1980’s they all started with giving their populations an HRA and building their wellness programs around the results. HRA’s are still in widespread use as there is tons of evidence that when you can help a population reduce their number of health risks everyone is healthier and healthcare costs are significantly reduced.

HRA’s are hugely incentivized by employers who will offer health insurance premium discounts and/or hundreds of dollars in cash to employees for merely completing them. One upside is that HRA’s today are often what get someone through the wellness coach’s door as they do a follow up interpretation session.

Over the years however, many of us have seen little value in HRA’s from the client’s perspective. Being told that if you eliminate a number of your risky (and often much-loved) lifestyle behaviors will add about 7.2 years to your life usually falls far short of providing what you would call stimulating motivation for change! Most of the coaches that I have trained who are already out there working with clients say three things about HRA’s: 1) we love them for the aggregate data they provide; 2) client’s do not find them motivating (fear based motivation is easy to deny and just doesn’t last); and 3) so many employees do not trust their employers to keep it confidential that they “fake good” on them when they fill them out.

So, for me, Edington’s talk was much anticipated. Dr. Edington began slowly talking boldly about how upon visiting the Lifestyle Medicine website he was disappointed to see that their definition of Lifestyle Medicine was not about health…it was about disease.

“Lifestyle Medicine (LM) is the use of lifestyle interventions in the treatment and management of disease.” (http://lifestylemedicine.org/define)

He then went on to remark how despite accomplishments in many areas, the impact of all our work in medicine, health promotion, etc. the health of the nation is in many ways no better today than it was thirty-five years ago when he began this work. The obesity epidemic and all the chronic diseases (lifestyle driven) that go with it are killing us. Looking back disheartened, he said that our health-risk reduction approach was a mistake. Looking back over thirty-five years and 12 million HRA’s administered, he said “I’d like to take most of them back. I was part of the problem.”

Here was the man everyone listened to for years and who lead an approach to wellness programming that thousands of companies and organizations followed, admitting that we have been on the wrong track all this time. What a huge realization, and what a huge admission!

“We’re in the mud, the muck, talking about risk factors and disease.” he said. What about health? What about real wellness? He urged us to consider instead of running away from healthcare costs, to run toward health!

It was another speaker who quoted Einstein that day (Arthur Franks) but it could just have easily fit into Dee’s Powerpoint presentation.

einstein-quotes-solve-problemsThe big challenge we face according to Dee is this question:

“How can you beat the natural flow of decreasing population health status?” His research was not all for naught. It showed us that if we provide nothing for the healthy people in a population to help them stay healthy they will become those high risk individuals with increasing health problems.

“Disruptive innovation!” is what Dee Edington is calling upon all of us in the health and wellness fields to do. We clearly need some new thinking if we are truly going to make a dent in the health problems we face. Innovate. Be bold.

Dee even chided the Holy Grail of “Evidence Based Medicine”. If you are oh-so-carefully following EBM he reasoned, “You are a follower. Be a leader!” he urged.

The outcome measures we should be shooting for are not these fearful risks, they should instead be things like “Engagement in life! Love, compassion and resiliency.”

Lifestyle medicine by it’s very nature is a form of “disruptive innovation”, as the wellness field was in it’s early years. What I now question is have we forgotten our innovative roots? In the late 1970’s when we got this wellness field moving it was indeed revolutionary. We shook up the status quo of remedial care and found more and more effective ways to look at what really influences health. Behavior. Culture. Belief. Connection.

As the years passed and every wellness program struggled for funding, and as the business model conquered the healthcare field with chilling completeness, we embraced the statistics, the algorithms, the data and, I think in many ways lost our way.

I would stand with Edington and ask us all “What is our vision of health and wellness?” What is our way forward so that we might once again embrace the whole person; mind, body, spirit and environment? We began this wellness journey almost forty years ago on the shoulders of Abraham Maslow and others who looked for ways we could help people live their best lives possible. When people are in fact on that journey to live their best possible life they are on the path of wellness. Let’s be the allies that help people find their way.

two-people-on-stroll-panorama

Being the Behavioral Change Expert: The WELCOA Wellness Coaching Interviews

Dr. Arloski Keynoting in Brazil

Wellness coaching is about setting aside your expert hat when it comes to wellness content and becoming the true ally your client needs for lasting lifestyle change. Yet, where our expertise shines through is in helping our client to actually succeed at making those behavioral changes that will improve their life and health. We need to be the behavioral change expert.

Healthcare organizations have discovered that health is largely behavioral in nature (consider medical compliance/adherence and the mind/body effect for examples) and have been embracing wellness and health coaching as a way to bridge the behavioral skills gap. To represent the field of wellness coaching I was honored to have the opportunity to be interviewed by Dr. David Hunnicutt of The Wellness Councils of America (WELCOA) in their “WELCOA Expert Interview” Series. I’ve known David since the early days of the wellness movement and our interview produced so much content that WELCOA decided to feature it in two parts. They also helped bolster the field of wellness coaching in this special coaching issue of their newsletter by interviewing my colleague, Margaret Moore.

Please go here for completely free downloads of all the interviews:
http://www.welcoa.org/freeresources/index.php?category=16

Please share these resources with you colleagues. I believe you will find these interviews to be some of the most succinct and helpful information that has yet been published on health and wellness coaching.

Be well!
Dr. Michael