Keys to Coaching Clients Who Overidentify With Their Illness



We like to say that a coach listens to a person’s story and helps them to realize that they are not their story.

For the health-challenged client, their illness, conditions, or health experience is a huge part of their story. “I am a diabetic.” While this is true, how strongly does the person now see themselves through this lens? What effect could it have on someone’s confidence that they can regain their health? How hopeless do they feel if they have framed their health challenge like a prison sentence instead of a challenge to be overcome? How different it might be if the same person could say “I’m a person challenged by diabetes.”

Erik Erikson, the renowned developmental psychologist who coined the term ‘identity crisis’, viewed identity “as the degree to which an individual integrates different self-assets into a coherent sense of self, and such a coherent sense of self translates itself into daily life and guides choices and values.” (Oris, 2018) When we think about a sense of self-guiding choices and values and apply this to making lifestyle choices, illness identity could play a huge role.

What happens to that coherent sense of self when a person is diagnosed with a life-threatening illness? What happens when that person may not only label themselves according to their health challenge, but is labeled by treatment professionals and even friends and family?

“Although most patients succeed in adjusting to their illness, some patients experience difficulties, which can negatively affect their physical and psychosocial functioning.” (Morea, 2008) Much of that difficulty comes when a client has over-identified with their health challenge.
As health & wellness coaches we know that attitudes and beliefs drive behavior. Each of our clients will react to their health challenge in their own unique way, but it may be very helpful for the coach to understand how these reactions or responses may be seen in terms of different dimensions or states of identification with the person’s illness.

Let’s look at keys to understanding and coaching strategy around client identification with their illness.

Key Number One: Understand the degree to which chronic illness dominates the client’s identity and daily life.

In 2016 an international team of scientists sought to understand this concept more deeply. Their work with adolescents dealing with Type One diabetes led this team to develop the Illness Identity Questionnaire and identify four illness identity dimensions or states: engulfment, (Oris, 2018) rejection, acceptance, and enrichment. (L.Oris, 2016)

Think of the term engulfment. Your client may be completely engulfed by their illness. “Individuals completely define themselves in terms of their illness, which invades all domains of life, at the expense of other important self-assets (Morea, 2008).” They may be experiencing continual physical reminders of their condition as symptoms of their illness manifest. If your client feels in the grip of such an illness, how hopeful are they? How disempowered do they feel that they can do anything about it? They may experience great fear that they will never get better. They may just not know what the future holds, but their illness has taken over their lives. It is quite likely that such a client may be in the Precontemplation Stage of Behavior Change when it comes to lifestyle improvement efforts.

Key Number Two: Meet your ‘engulfed’ client where they are at with compassionate understanding.

A client experiencing their illness this way may feel overwhelmed and helpless. The illness is so figural in their life that they seem to process their entire life through the filter of their health challenge. We want to convey sincere empathy but be prepared to have it either well or poorly received. Our client may feel like nobody else could understand what they are going through. Use your process coaching skills to help your client to work through some of the emotional load they are carrying. Slow down on setting up ‘what to do about it’ strategies. Your client is far from the Action Stage.

If your client has been stuck in this stage for months after their diagnosis or health event, consider what else might be going on. They could be experiencing some secondary gain. That is, they may be receiving some kind of reinforcing experience for staying stuck where they are. Family and others could be treating them with such extra kindness that it makes their overidentification rewarding. Be careful how you approach this subject as clients may feel accused and judged if you are too forthright about this. You might instead approach their situation from the angle of nurturing hope.

Part of what can increase hope is learning more about their illness and their prognosis and potentially what they can do about it. Inquire what they know about their health challenge. Share with them the information that patients who know more about their illness and treatments have better outcomes. Let them know that lifestyle improvement may not cure their illness, but it can significantly affect the course of that illness.

Key Number Three: Understand the Rejection Dimension of Illness Identification

While some clients embrace an identification with their illness others do their best to reject it as much as possible. “…rejection refers to the degree to which the chronic illness is rejected as part of one’s identity and is viewed as a threat or as being unacceptable to the self.” (L.Oris, 2016) This client avoids thinking or talking about their illness and they tend to neglect it, which results in poor treatment adherence. Their approach is one of denial and/or minimization. They attempt to go on with life and business as usual to the point where their biometric markers (e.g. blood sugar levels, blood pressure, etc.) worsen.

Attempting to persuade such a person to follow their doctor’s orders and begin improving their lifestyle will almost certainly go nowhere. If you are given the opportunity to coach such a person, instead take a holistic explorer approach. Have them tell you the story of life before their illness and what led up to their diagnosis. Ask them what the experience of hearing that diagnosis was like. Meet them with empathic understanding. Inquire about what it feels like they have lost. Often the experience of a loss of health is central to such a response to a life-threatening illness. (See my blog post “Astonishing Non-compliance – Understanding Grief and Readiness for Change in the Health Challenged Client” https://wp.me/pUi2y-n2)

This client may be the farthest away of all from the Action Stage and firmly entrenched in Precontemplation. Refer to Changing To Thrive, by Janice and James Prochaska (https://jprochaska.com/books/changing-to-thrive-book/) for extensive guidance on how to coach someone through the stage of Precontemplation.

Key Number Four: Coach the accepting client at a higher level of readiness to change

The acceptance dimension of illness identity shows a client who is not overwhelmed by their chronic illness, does not deny it, but rather accepts that this is their reality. “Chronic illness plays a peripheral role in one’s identity, besides other personal, relational, and social self-assets, and does not pervade all life domains.” (Morea, 2008) Such a client will be trying to lead as normal a life as possible without being in denial about their illness. They, to one degree or another, are finding ways to adapt to their illness.

Explore with this client their current level of knowledge about their illness and treatment. Inquire about the lifestyle prescription that their treatment team has recommended and how successful they have been at achieving those recommended lifestyle changes. Explore their motivation that fuels their desire to deal more successfully with their illness. Help them create a fully integrated Wellness Plan for how to move forward and affect the course of their illness in a positive way.

Key Number Five: Partner with the possibility of transformation

The fourth illness identity dimension, enrichment, provides the coach with a unique situation. Here the client has developed to where they frame their illness as an opportunity for growth and transformation. They see positive changes in themselves having taken place as a result of these negative developments in their health. “Such positive changes manifest themselves in different ways, including an increased appreciation for life, changed life priorities, increased personal strength, and more positive interpersonal relationships.” (Tedeschi, 2004) Coaching with a client who has reached this state of identity with their illness would be a delight. Here the focus might be more upon maintaining good self-care and treatment adherence, and possibly upon continued improvement in health. Such a client might be motivated to work on disease reversal through lifestyle improvement such as we see with programs like that of Dean Ornish. (https://www.ornish.com)


Content for the blog has come from Dr. Arloski’s forthcoming book Masterful Health & Wellness Coaching: Deepening Your Craft, published by Whole Person Associates, Inc., and is fully copyrighted.

Stay informed about the book’s publication at https://wholeperson.com/store/masterful-health-and-wellness-coaching.html

REFERENCES:

L.Oris, J. S. (2016). Illness Identity in Adolescents and Emerging Adults With Type 1 Diabetes: Introducing the Illness Identity Questionnaire. Diabetes Care, 757-763.
Morea, J. M. (2008). Conceptualizing and measuring illness self‐concept: 571 a comparison with self‐esteem and optimism in predicting fibromyalgia adjustment. Research in Nursing and Health, 563-575.
Oris, L. L. (2018). Illness Identity in Adults with a Chronic Illness. Journal of Clinical Psychology Medical Settings, 429-440.
Tedeschi, R. G. (2004). Posttraumatic growth: conceptual foundations and empirical 604 evidence. Psychological Inquiry, 1-18.

Michael Arloski, Ph.D., PCC, NBC-HWC is CEO and Founder of Real Balance Global Wellness (https://realbalance.com) a premier health & wellness coach training organization that has trained thousands of coaches around the world.

 

2010-2020 A Decade of Growth for Wellness Coaching

After years of building a foundation, health and wellness coaching has flourished in the last decade. At the beginning of this last decade the International Coach Federation was only fifteen years old and the National Board for Health and Wellness Coaching hadn’t even been thought of yet. My book, Wellness Coaching for Lasting Lifestyle Change, had been on the market for only three years, and The Coaching Psychology Manual, for only one. Thousands of people were already trained and working as health and wellness coaches, but the numbers were nowhere near where they are today. Wellness coaching was being used by employee wellness programs, disease management and insurance companies but had not made its way into the clinical world much at all. There was considerable success where wellness coaching was being applied, but the research to back it up was lagging. As the decade moved along towards 2020, everything shifted. Health and wellness coaching has truly arrived!

In the last ten years we have seen the profession of health and wellness coaching grow both in its application and as a true profession with standards and credentialing. Early in 2010 the National Consortium for Credentialing Health & Wellness Coaches was formed to develop and establish those standards and a system of credentialing. After an untold number of hours of work by dedicated coaching professionals this evolved into the National Board for Health & Wellness Coaching that we have today. Now, in addition to certification that coaches can receive by the organization that trained them, they can apply to become certified through the NBHWC by qualifying for and passing an examination administered by the National Board of Medical Examiners. Prospective coaches can now choose to be trained by qualified organizations that have earned approval by the National Board, ensuring great quality for their educational experience.

Importantly the critical research evidence backing up the incredible effectiveness of health and wellness coaching has mushroomed. We now have hundreds and hundreds of solid peer-reviewed journal articles making the case for health and wellness coaching.

My observations over the past decade is that the growth of health and wellness coaching has particularly accelerated in three areas: universities, the international arena and clinical/lifestyle medicine. Let’s look at the role Real Balance Global Wellness has played in each.

Loma Linda University

Early in the decade only a handful of schools were offering programs that included health and wellness coaching. These were mostly schools of Integrative Health or related areas. Leaders such as The California Institute of Integral Studies, Duke University, and the University of Minnesota were such innovators. As more and more schools discovered that health and wellness coaching offered their students a practical skill set and a needed certification in the field, actual training in health and wellness coaching became highly desirable. Real Balance began to partner with schools of Public Health, Nursing, and a variety of programs to not only deliver direct training, but to train college and university faculty to become Real Balance Trainers and be able to deliver our curriculum and certification. Our program nurtures such schools along until they are ready to apply to the National Board to become an approved program in their own right.

China!

As lifestyle diseases have replaced infectious disease as the number one cause of premature death, the value of health and wellness coaching is being increasingly recognized around the world. Interest is growing fast in Europe, Asia and Latin America. Real Balance truly became Real Balance GLOBAL Wellness in this last decade. We developed training programs in Ireland/UK, Brazil, Australia, and China. We delivered keynotes and programs in the Azores Islands of Portugal, and the Philippines. Students from around the globe continue to become trained as health and wellness coaches through our live webinar classes.

The third area of growth for health and wellness coaching that has ballooned especially in the last few years of our past decade is primary care/lifestyle medicine. The recognition that a large component of our health is behavioral has led to the greater openness to the role of health and wellness coaching in direct medical services. Health and wellness coaches are helping patients to be more successful at medical compliance/adherence, and at accomplishing the directives of the lifestyle prescription recommended by their treatment team. The tremendous growth and increasing acceptance of the principles of lifestyle medicine has helped health and wellness coaches to be seen as a very practical solution for the behavioral changes sought by physicians and other healthcare practitioners. The recent granting of a Level Three CPT Code for health and wellness coaching is a huge step forward. Though direct reimbursement is a ways off, the new code helps legitimize health and wellness coaching in the eyes of the medical world and opens doors.

Health and wellness coaching enters this new decade with an earned respect. We have the evidence of our effectiveness, solid professional credentialing and standards, international awareness, and a recognition that we can play a key role in improving health and wellbeing all around the world. Be a part of helping us take it forward!

Michael & Deborah Arloski

Emotions, Feelings and Healthy Choices: Coaching for Greater Wellness

One of the first things we learn about in the fields of Wellness & Health Promotion and Health & Wellness Coaching, is that our lifestyle choices are a primary determinant of our health and wellbeing. It seems straightforward that making the right or healthy choice is a rational process based upon having the best information. We often then address how challenging it is for a person to put that choice into practice by looking at their social support, environmental conditions, etc. Much of the focus for wellness coaching becomes helping our client to create a wellness plan based upon those healthy choices and implementing with support and accountability. Let’s stop and take a closer look at those decisions.

Anyone in the healthcare or wellness fields is keenly aware that clients don’t always opt for the best, or healthiest choice. They also often observe clients changing these choices for no apparent reason. One day our client is convinced to start working towards a largely plant-based diet, and on another day, they show little if any desire to do so. We can explore ambivalence, of course, but what is really going on in our client’s decision-making process?

Applying what we know about the role that emotions play in decision-making can be extremely useful to the wellness coach. Learning how to coach our client in this emotional realm is often critical to their success. (See my previous post: “The Great Utility of Coaching In The Emotional Realm”, https://wp.me/pUi2y-lA)

Emotions and Making Lifestyle Choices

Making lifestyle choices are like any other decision-making process – they are more complex than it seems at first. Understanding how our emotional bias fits into this process may help coaches to be less perplexed by some of the self-defeating lifestyle choices we see that our clients have made and continue to make.

Emotions are a heavily researched area of psychology and it is easy to get lost in its vast literature. In an especially succinct article, Executive Coach Svetlana Whitener synthesizes the work of several key researchers and conveys a useful paradigm to coaches to learn from. (“How Your Emotions Influence Your Decisions”, https://www.forbes.com/sites/forbescoachescouncil/2018/05/09/how-your-emotions-influence-your-decisions/#5eece5313fda)

Emotions emerge as a response to external stimuli, or the recollection of it, or the imagining of it. “That stimulus generates an unfelt emotion in the brain, which causes the body to produce responsive hormones. These hormones enter the bloodstream and create feelings, sometimes negative and sometimes positive… So, to review, it’s stimuli, then emotions, then hormones and, finally, feelings. In other words, your emotions impact your decision-making process by creating certain feelings.” (Whitener, 2018)

 

How we interpret or frame those feelings and how we respond to them results in our choices executed in our behavior.

In this model it is not the emotions that we are aware of, it is the resultant feelings that we feel. When our clients contemplate making lifestyle changes, they often experience a variety of feelings. They may experience positive anticipation or dread. The memory of past failures may bring up the emotion of fear resulting in feelings of embarrassment, regret, shame or guilt. Likewise, a history of more pleasant experiences may lead to positive anticipation. What Stage of Change the client is in may be heavily influenced by the feelings they are experiencing.

Expand Your Emotional Vocabulary

Psychologist Paul Ekman’s research on emotions opened a huge doorway to understanding how people express themselves. A key from his work that can help the coach is to look at how (as in our model above) emotions generate feelings and how those feelings differentiate. Researcher Tiffany Watt Smith has listed 154 different worldwide emotions and feelings. (1). Studying Ekman’s Wheel of Emotions can help a coach to expand their own knowledge and use of emotional terminology. As you coach with your client you can explore more possibilities to help your client clarify exactly what they are feeling.

 

Ekman’s Wheel of Emotions

 

 

 

 

How The Coach Can Help: Coaching With Emotions and Feelings

1. Coaching Presence – Your coaching presence sends an ongoing message that either gives permission to explore feelings or denies it.
2. Notice – Be keenly observant of the emergence of feelings on the part of your client. Be continually scanning not just their words, but how they say them. Hear the changes in tone of voice, volume, rapidity, etc. Notice all of the nonverbal information you can gather.
3. Contact – Help you client to connect with their feelings. Use the Active Listening Skill of Reflection of Feelings. Share observations of patterns you see. “I’m noticing that each time you talk about taking time for self-care you begin speaking about your partner.”
4. Name it – Help you client to name their feelings. As we saw above emotions can generate a wide variety of feelings. Expand your own emotional vocabulary and help your client to drill down to what they are truly experiencing. “Well, it’s not really anger, it’s more like resentment.”
5. F.A.V.E. – First Acknowledge the client’s experience and what they have been through. Then Validate their feelings. It’s okay for them to feel the way they feel about it. (Regardless of how rational or appropriate their feelings may seem.). You absolutely must not judge their feelings. Most importantly Empathize. Show real empathy and compassion and put it into words.
6. Process – Help your client to explore and process their feelings. Allow them to expand and talk about them. Once the initial release has taken place, they will usually start to analyze what is going on for them, looking to make sense (and meaning) out of their feelings.
7. Insight – Is your client able now to gain some insight from what they have learned in this process?
8. Application/Integration – Are they able now to take their insights and turn them into action? Now you can coach your client on ways they can modify their behavior or create experiments in their lives to improve their lifestyle.

Note – If you find that you are answering the questions in items 7 & 8 with the negative, your client may benefit more from counseling instead of (or in addition to) coaching. That is, if they just continue to process feelings, and process feelings without it leading to insight, or if they are unable to put their insights into action, and instead return to processing feelings (and emoting), then begin to explore the alternative of counseling. See my blog on this topic – Coaching a Client Through To A Mental Health Referral Using The Stages of Change (https://wp.me/pUi2y-lp).

A wellness coach may think that it is their job to get their client to make the right lifestyle choices. When coaching deteriorates into convincing or persuading, we are stepping away from the coaching process. We can certainly warn our clients about misinformation they may have about fad diets, or unproven remedies, etc. However, effective coaches honor their client’s autonomy. The reality is that after a coaching session, our clients will go on living their lives doing what they choose to do despite our urging. Trust the coaching process. Help your client to factor in their emotions in a more conscious way so that the lifestyle choices they make are working for them instead of against them.

References
(1) Tiffany Watt Smith. “The Book of Human Emotions: An Encyclopedia of Feeling from Anger to Wanderlust” (PDF). Anarchiveforemotions.com. Retrieved 2017-05-28.
(2) Ekman, Paul (1999), “Basic Emotions”, in Dalgleish, T; Power, M (eds.), Handbook of Cognition and Emotion (PDF), Sussex, UK: John Wiley & Sons.

Dr. Michael Arloski

Michael Arloski, Ph.D., PCC, NBC-HWC, is a psychologist, professional coach, author, trainer/educator and CEO and Founder of Real Balance Global Wellness. Follow his blog at https://realbalancewellness.wordpress.com, and his presence on Facebook (https://www.facebook.com/michael.d.773), Twitter https://twitter.com/DrMArloski) and LinkedIn (https://www.linkedin.com/in/realbalance/).

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.

China Embraces Real Balance Wellness Coaching

Real Balance Wellness & Health Coach Certification Class in Shanghai – 2017

Faced with the same lifestyle-based health crisis many other countries are experiencing, China has been searching for a way to help people truly succeed at lasting lifestyle change. Over half of the men in China smoke. The diabetes rate is now higher than the United States, with heart disease, COPD and other “lifestyle diseases” on the rise. Health information campaigns and medical admonition, as elsewhere, has only gone so far. Last month when Real Balance Global Wellness Services, Inc. (https://www.realbalance.com) teamed up with Chestnut Global Partners China EAP (http://chestnutglobalpartners.org) to bring live wellness and health coach certification training to China it was enthusiastically embraced.

The concept of wellness is new to China, and wellness & health coaching is even newer. Though there is a long tradition of Traditional Chinese Medicine that blends with Allopathic Conventional Medicine, these are still remedial treatments and do not address how to help someone improve lifestyle behavior. Smoking cessation programs are vigorous but face a huge challenge in this population. Wellness coaching provides an innovative way to make behavioral change possible for those who need it.

What impressed me most about my entire trip to China were the students in our live training in Shanghai. The class was composed partly of Chestnut Global Partners EAP employees. These were mostly physicians and department directors. The rest of the class was a mix of M.D.’s, dieticians, counselors, Human Resources professionals and even a few independent life coaches. Throughout our grueling six-day training their level of engagement was extraordinary. While all students are faced with the “mindset shift” challenge (going from a prescriptive, consultative way of interacting, to a coach approach), this group did so with less resistance than we anticipated. They really got the concept that when it comes to helping people change behavior, it is very different from treatment or education. Fortunately, the training I delivered was coordinated with my translator and co-trainer, Dr. Li Peizhong, psychologist and V.P. of Chestnut Global China. He performed live translation as I spoke, and added greatly to the interaction and processing.

All of our trainings are highly interactive, and when students shared information and stories of work they had done with patients and clients, the level of humor employed was amazing! Much was “lost in translation” for me, but they were continually breaking out into boisterous laughter. Also, the Chinese students were more natural in their continual use of empathy in their coaching practice. While they tended, like students everywhere (we’ve found), to jump right into problem solving first, they used empathy and spoke of the importance of it, more than any other group I have trained.

Chinese culture is well known for valuing the group. As our training went on, group cohesion increased rapidly. Students supported one another in their learning through a real sense of caring for one another. When one student volunteered to be our client for a round of “fishbowl coaching” practice (where a student works on a real life challenge and is coached by a number of students) she left the exercise still perplexed about a way forward. Students formed a circle around our volunteer student and spent their entire break time collectively discussing with her about how to address her challenge.

The other evidence of this collective spirit was in the almost instant formation of a class group on the app WeChat. Before the training was even finished, and then vigorously once it was complete, they were on WeChat (http://www.wechat.com/en/) connecting, lining up their Buddy Coaching, and then sharing photos and stories of how they were following through on their own lifestyle improvement action steps.

Practicing Tai Chi On The Great Wall

The students were unbelievably appreciative, kind and treated me like royalty. I had integrated some of my Tai Chi and Xi Gung practice into our energy breaks, much to the delight of the students. At the conclusion of the training, at our celebratory class dinner they gifted me with a beautiful white Tai Chi practice suit to show their appreciation.

On To Beijing!

After our training in Shanghai, we flew to the country’s capital, Beijing, for a special Book Release Event. At Peking University (yes, it is spelled differently), Chestnut Global and my publisher, The China Translation & Publishing House, hosted a large gathering of executives from several multi-national corporations, representatives of the Chinese government’s smoking cessation program, and others, to witness the release of my book, Wellness Coaching For Lasting Lifestyle Change, 2nd Ed., (https://wholeperson.com/store/wellness-coaching-for-lasting-lifestyle-change.shtml)  in its Mandarin translation. Speakers from Chestnut Global, Peking University, and the government’s smoking cessation program joined me in delivering talks to the very receptive audience. This was followed by one astonishing Chinese banquet.

A World of Wellness

I have been fortunate to take our training to a number of countries around the world and each experience has been special. The beautiful thing is that whether it is a training session in Indianapolis, Sao Paulo, Dublin, Shanghai, or Fort Collins, our students know that this training is going to make their work so much more effective. They know it is going to make their work so much easier, and more rewarding. They know it is going to help them enhance the lives of others.

I’ve stood at the front of the room around the globe, but it is the people who stand behind me that really make it all possible. It’s the allies we’ve formed in other countries and it’s the people right here at home. I’m able to write books and deliver keynotes and trainings because others are operating the office, servicing our students, teaching classes and representing Real Balance to the world as well. I come back from China with a heart full of hope for the people of our planet and with gratitude for those who help me step out there and make it a better place.

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

 

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