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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The Tao of Wellness Coaching – Part One – What Centers Us?

What can today’s health and wellness coach learn from The Tao that will make their job easier and more effective?

When I let go of what I am, I become what I might be.
Lao Tzu

History and Context

It is said that the legendary Chinese sage, Lao Tzu, rode off on the back of an ox when leaving the Middle Kingdom. Before a sentry guard would let him pass out of the city gates, he asked the sage to write down his teachings for the good of all. The result was the seminal text, The Tao Te Ching. Lao Tzu then rode off into the wilderness, never to be heard of again.

The wisdom of this book was never lost from those times (5th-6th Century BCE), but instead spawned a philosophy that holds real merit for our lives today. Our challenge is to bring the Tao, or “the Way”, into those busy lives and, ultimately into every aspect of our being. When we do, we operate very differently. We engage in our work in a different way. We experience stress but respond to it more effectively. We coach differently.

The Tao is a concept cloaked in mystery for most of us. Sage sayings that sound like one conundrum after another leave us puzzled. “Those who know do not speak. Those who speak do not know.” “Yield and overcome; Bend and be straight.”― Lao Tzu, Tao Te Ching. Yet, there is a strong appeal because we often covet the apparent peace of mind that practitioners of the Tao seem to have. They seem, so “centered”. They seem to have a quite confidence that guides them. They know just what to do.

When we speak of the Tao and wellness coaching we are not implying that to know the Tao one must study and adopt the more religious form of Taoism. Taoism is most often defined as a philosophical tradition that is all about living in harmony with life, or literally translated, “The Way”. One can pursue living in harmony with the way of life without necessarily becoming involved in a religious pursuit, per se. Carolyn Myss tells us that living in harmony with the Tao is a way to “reduce the friction inherent in most of life’s actions and to conserve one’s vital energy.” (1) Studying the philosophy of Taoism, the Way of the Tao, however, holds great potential benefit for coaches.

The bookstores of the world are packed with books with titles such as The Tao of Business, The Tao of Golf, The Tao of Leadership, The Tao of Physics and an infinite list of variations on this theme. Clearly many find value in this ancient wisdom and have found ways to make it relevant and advantageous. Psychologist Wayne Dyer studied the Tao for an entire year and provided us with a deep resource with his book Change Your Thoughts – Change Your Life: Living The Wisdom of the Tao (2009)(2). There are many translations of The Tao Te Ching, but for the Westerner, Dyer’s book may be the best introduction because it explains so many of the concepts in ways we can apply to our everyday, and professional lives.

What Centers Us In Life

There are many things that ‘center’ us in our lives. Being centered is about living our lives in a healthy balance and getting our needs met so that we have vitality. Many things do this for us. Ask yourself: what keeps you in balance, what centers you. You may say getting regular exercise, gardening, reading fiction, connecting regularly with friends, getting out in nature, getting enough rest, etc. All of these activities and more help us to be more in balance, to live a wellness lifestyle, to be in harmony with the Tao. It all seems to be saying the same thing.

Our wellness lifestyle forms the foundation for this centered way of living, but any number of mindfulness practices can help us take it further for even more benefits. Practicing Yoga, various forms of meditation, Mindfulness Based Stress Reduction, Contemplative Prayer, and other methods can all help ‘center’ us and not only teach us the ways of the Tao, but actually alter our psychophysiology in a positive way. All of these practices have the potential to help us shift our nervous system more into what is know as the Relaxation Response (Benson, 2000), the activation of the parasympathetic branch of our autonomic nervous system. This results in a lowering of heart rate, blood pressure, etc., and therefore makes it easier for us to be calm and less reactive to stress, in other words, more centered.

The Tao In Movement

Practicing Tai Chi On The Great Wall

Tai Chi is a Taoist inspired soft martial arts practice, a moving meditation actually, that embodies many principles of the Tao. The health benefits of Tai Chi are well documented. “Tai chi is often described as “meditation in motion,” but it might well be called “medication in motion.  “There is growing evidence that this mind-body practice, which originated in China as a martial art, has value in treating or preventing many health problems.” (http://www.health.harvard.edu/staying-healthy/the-health-benefits-of-tai-chi) (3) The benefits one can derive from such a practice, however, go well beyond the psychophysiological.

For me, practicing Tai Chi has been a non-cognitive way to study the Tao. It is ‘centering practice’. I was fortunate in the late 1980’s, to learn the short form of the Yang Style of Tai Chi taught by a physician from China. My practice since then has been consistent, if not as frequent as I would like. The result of regular practice is a centered way of moving, and, to an increasing degree, a centered way of being. This is living in harmony, with the Tao. For me it has been a thirty-year journey in somatic learning.

When we move from center we are always in balance. Think of the martial artist in action, such as a practitioner of Karate, Aikido, or Tai Chi Chuan. For them to be effective in combat they must move from center. If they aggressively lean too far forward they land on their face, or if they are too afraid and lean backwards they end up on their backside. Think of how this same principle applies to a sales person attempting to make a sale, an instructor attempting to get a point across, an encounter that you may have attempting to resolve conflict with someone. Think of how this applies to our coaching. The metaphor holds up. If it did not go well, we might realize that we weren’t very centered.

Centered Coaching: What The Tao Has To Teach Us

When I observe masterful coaching the style of the coach may vary, but one thing is always present: centeredness.

A centered coach speaks less and listens more. They can “dance in the moment” effortlessly, going wherever the client needs to go, no matter how unexpected. They are not attached to outcome, but are focused on results. A centered coach can shift into new directions, but remains grounded in structure and the foundations of coaching. Such a coach has no need to impress or appear powerful. They don’t work at being powerful, yet they are. Centered coaches do not push their own agenda, yet they do not collude with their clients either. They know when to push, to confront, and have the courage to do so. They also know the power of yielding.

Mastering others is strength. Mastering yourself is true power.
Lao Tzu

In Part Two

Effective wellness coaching is, inherently, very much in harmony with the Tao. In Part Two we will look at two key Taoist concepts and how they apply directly to wellness coaching: Ying/Yang balance, and the concept of Wu Wei or Effortless Effort.

References

1. (Carolyn Myss, https://www.myss.com/free-resources/world-religions/taoism/philosophical-and-religious-taoism) – taken from web 7.5.17)

2. Dyer, Wayne. (2009) Change Your Thoughts – Change Your Life: Living The Wisdom of the Tao. Hay House.

3. “The Health Benefits of Tai Chi”. Harvard Women’s Health Watch. Harvard Health Publications.
(http://www.health.harvard.edu/staying-healthy/the-health-benefits-of-tai-chi

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.

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!

Client-Centered Directiveness: An Oxymoron That Works – Part Two: Adapting To Your Client

Just how much directives does our client need?
Just how much directiveness does our client need?

Effective wellness and health coaching adapts in many ways to the client we are working with. As we assist a person in finding ways to live a healthier life there are many adjustments that need to be made to deliver a customized experience that will work best for that individual.

In this post we will examine how to take into account several key client determinants that will guide our choices about just how directive to be with our wellness coaching clients. Truly one size of coaching does not fit all.

In our last post – Client-Centered Directiveness Is Not An Oxymoron – Part One (http://wp.me/pUi2y-jO), we explored how coaches vary in the degree to which they are directive or non-directive. We looked at how there is a Directiveness Continuum that allows for an effective range of coaching in the middle and ineffective coaching at the extremes. We explored the Coaching Spectrum of techniques and methods that ranged from listening and understanding to ways that we might not consider coaching such as directly telling people what to do. We also looked at all of the ways that coaches are, in fact, engaging in directive work with their clients, and how to do so effectively.

Wellness coaching clients vary tremendously on both mental/emotional and environmental variables. One client may be highly motivated to improve their lifestyle and very open to and welcoming of coaching. They may have abundant resources at their disposal and great support from other people in their lives. Or they may be the mirror image of all of these qualities. Some of our clients may be familiar with coaching from experiences with business/life coaching, or from having had some form of telephonic wellness coaching as a benefit from their employer or insurance company. Many, of course, will be very unfamiliar with wellness coaching and how it works.

One way to adjust to what our client needs it to see where they fit into the following matrix:

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If we just look at the variables of Experience, Control, Motivation and Ability we can see how we might work with these combinations in either more directive, less or non-directive and blended approaches. Experience may refer to more or less experience with coaching or with the process of changing lifestyle behavior. Control may refer to the client’s own needs for control, or how “in charge” they like to be. Motivation may refer to motivation to engage in the coaching process, and/or motivation to improve one’s lifestyle. Ability may refer to intellectual ability, or to environmental circumstances that limit the client’s ability to engage in lifestyle improvement efforts. The matrix is not perfect. We could, for example have a client who is of Low Ability and Low Motivation, but who has High Needs for Control. In such situations we would have to decide which variable trumps the others. In this case, I personally would recommend honoring the High Needs for Control as paramount. Perhaps this illustrates that someone will always have their own unique position in the matrix and require us to adjust the degree to which we are directive or non-directive. We might imagine their location being plotted like somewhere on a graph, as in our example, near the top of the Directive Quadrant, closer to the border with the Blended Quadrant. In other words we are not advocating a simplistic four-quadrant approach to coaching, but again, honoring the unique position of each of our clients on the matrix.

Examples – Ronaldo and Hazel

Let’s say our client, whom we’ll call Ronaldo, is an industrial design team leader who has had some experience with leadership coaching. He’s struggling with stress, sleeping well and his biometric markers have hit an alarming borderline zone with his blood sugar, blood pressure and blood lipid levels. He’s very concerned about this and highly motivated to engage in coaching and make some positive, and immediate lifestyle improvements. He clearly fits somewhere in our Non-Directive Quadrant on our matrix. Coaching with Ronaldo will most likely proceed, as it would with all of our clients, building a strong coaching alliance, using an effective coaching methodology and structure. Ronaldo will want to feel like he is definitely the one with his hands on the steering wheel. All of our steps together will be CO-CREATED. Ronaldo will need little in the way of suggestions or even education, but he may benefit tremendously from a great ally to strategize with, a strong system of support, and what we might call “gentle” accountability.

Another client of ours, whom we’ll call Hazel, is a hardworking housekeeper with a large hotel chain. She has never had any experience with coaching and is unfamiliar with what it can offer. She’s finding that despite her high level of physical activity she still continues to gain weight. She is also very discouraged from many failed attempts at crash dieting. Accurate information about how to eat better has been lacking for her. She finds learning new systems difficult and doesn’t really like change. Her family situation also contributes to making lifestyle improvement challenging. Hazel would fall somewhere more into our Directive Quadrant. Again, we would be treating Hazel with the same high level of honor and respect that we would with all of our clients in building a powerful coaching alliance. We would avoid stereotyping Hazel or making assumptions about her abilities. We would however, be realistic in meeting her where she is at. Hazel would most likely appreciate a more directive approach. She may benefit from recommendations for nutrition education resources. If the coach is a qualified dietician or nutritionist, they may want to create an agreement to combine these roles into the coaching that is done and “wear two hats.” The coach may take on a role where they are guiding the client through the coaching methodology more carefully, yet keeping it client-centered with Hazel still being in charge of choosing each step that she wants to do. Accountability agreements may need to be adjusted more closely to make sure that Hazel is clear about the agreements, and sees the value in them for her.

mappointingdirection“Just tell me what to do!”

There are times when clients more like our “Hazel” really ask the coach to simply tell them directly what to do. How should I exercise? What should I eat? Usually such clients are discouraged by past failure experiences and their own self-efficacy is so low that they have no faith in their own ability to create an effective way to change. They seek consultation more than coaching. They want a real “expert” to direct them on the “right” path. A great coaching response to such requests goes something like this:

“So, when you’ve asked the experts about what you should do, and followed their advice, how did that work for you?”

Almost always the person will think for a moment, sigh, and then have to admit that while such expert advice may have worked for a short amount of time, eventually it didn’t work at all. That’s when you can lightheartedly suggest that you and your client defy the so-called definition of insanity – doing the same thing again, and expecting different results! We need to meet our client’s request for complete direction (to the point of consultation, not coaching) with empathy and understanding. Keeping them in charge, remaining client-centered can still be done, even though we may coach them in a more directive style.

Staying True To The Coaching Mindset

No matter how directive or non-directive we are with our client, we still will be coaching from a stance where we hold them to be Naturally Creative, Resourceful and Whole. (http://www.coactive.com/learning-hub/fundamentals/res/FUN-Topics/FUN-The-Co-Active-Model.pdf) Our task is still to Evoke our client’s Inner Wisdom. Some of our client’s may have gotten to the point of doubting they even have such wisdom and strength. This is where it is good to remember the famous quote from Goethe.

“If you treat an individual as he is, he will remain how he is. But if you treat him as if he were what he ought to be and could be, he will become what he ought to be and could be.” Johann Wolfgang von Goethe

 

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

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

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

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

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

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

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

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

What they found was frankly, not a lot.

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

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

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

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

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

Healthy Choices For A Lifetime
Healthy Choices For A Lifetime

The Five Keys of Coaching For A Lifetime of Wellness

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

1. Build Self-Efficacy

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

2. Nurture Visionary & Intrinsic Motivationgreen nature_wood path

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

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

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

3. Focus On The Maintenance Stage (TTM)

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

4. Co-create Relapse Prevention Strategies1369010631_url

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

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

5. Coach For Connectedness

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Be well! Coach MichaelM-ConamaraDiamond1

 

 

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