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 Two – Practical Applications

Photo by Michael Arloski

When the best leader’s work is done the people say ‘We did it ourselves.’                                Lao Tzu

In Part One –  In the previous post “The Tao of Wellness Coaching – Part One – What Centers Us?”   http://wp.me/pUi2y-lN   we grounded ourselves in the history and context of The Tao and the concept of Centered Coaching. We examined how relevant the practice of Tai Chi can be.

Essential Concepts

Effective wellness coaching is, inherently, very much in harmony with the Tao. Let’s look at two key Taoist concepts and how they apply to wellness coaching.

Yin-Yang Balance

Fundamental to Taoist thought and foundational to Chinese Medicine is the concept of Yin and Yang. These are the polar opposite, yet complementary, forces of the world that, for health and wellbeing to exist, must be in balance. The Yang forces are active, positive, hot, overt, masculine, light, and hard. The Yin is passive, yielding, negative, cool, quiet, feminine, dark, and soft. In the classic symbol the Yang rises to the top and is represented by the light area with the black dot in it, while the Yin sinks to the bottom and is represented by the black area with the white dot in it.

The key is to understand that the two are opposite, yet interdependent, complementary and interconnected. When we experience having too much of one and not enough of the other, we experience dysfunction whether it is at the physical, psycho-emotional or behavioral and practical level. Regaining balance becomes the return to a level of healthy homeostasis.

As coaches work with clients to achieve a wellness lifestyle the goal of achieving a healthy balance is paramount. We must rest, but not become lethargic. We must move and exercise, but not to the point of exhaustion and fatigue. We must find a way to take in sufficient calories, but find the right level for our optimal health, etc.

As coach and client co-create a wellness plan the concepts of Yin and Yang can be very useful. Our culture tends to reinforce and promote the Yang forces while not supporting those of the Yin. We are urged to be productive, work hard, play hard, achieve, accomplish, try harder and push. Seldom are we reinforced, much less accommodated for self-care activities such as getting adequate sleep, relaxing, taking time to get a massage, meditate, or enjoy our leisure. In fact, we may face criticism for such ‘indulgence’.

Many components of a wellness plan involve greater frequency of self-care activities. As clients look at their health and wellbeing through a more holistic lens, they often see the value of taking more time to meet these needs to balance their lives. Often these same clients have been admonished by their healthcare providers to engage in more self-care activities in order to improve their health. Many times wellness coaches work with clients who have been foregoing their medical self-care, such as taking time to do self-testing (e.g. diabetes), following up on medical appointments, doing rehabilitation exercises, etc. Instead they have been consumed and distracted by the Yang-style demands of their work, and their own belief systems.

When wellness coaches work with their clients to construct ways to manage stress more effectively, they are inevitably working to achieve Yin-Yang balance. Without ever speaking of the terms (Yin and Yang), we might consider how all actions possess either Yin or Yang energy and help our clients to decide how much to include in their lives. There may be great stress management wisdom in exploring strategically with our clients when it is best to push, and when to yield.

At a fundamental level our clients are often in a state of ambivalence about change that displays the push-pull of Yin and Yang forces. Should I, the client, change my way of living, or not change? When we really examine the ambivalence resolution methods of Motivational Interviewing (MI) we can see a Taoistic stance taken by the therapist or coach. The coach does not “pull” for one path to be taken over the other. Instead, they neutrally allow the client to explore and experience both energies; change and no change. The coach using this MI approach remains as centered and non-judgmental as possible helping the client to weigh the pros and cons (again a Yin/Yang process).

Wu Wei – Effortless Effort

Living in harmony with the Tao is about letting nature take its course and not interfering with the natural order of things. The concept of Wu Wei conveys the idea on ‘non-doing’, ‘non-action’, or ‘non-intervention’. This concept seems antithetical to Western thinking. In Western culture we are taught to make things happen. In Western Medicine the expert seeks to find the best intervention and implement it as soon as possible. To accomplish a desired outcome by ‘allowing’ things to simply be and progress on their own seems either too slow or doomed to failure. Yet think for a moment. Have you ever needed to relax and unwind and the harder you tried to do so, the more anxious and tense you got? There is only one way to relax; you have to allow yourself to do so. When we intervene medically to treat a wound, the actual healing that follows is something we have to patiently allow to happen.

Wu Wei is perhaps best thought of as living in a state of effortless harmony and alignment with the natural cycles and ways of nature. We are truly ‘going with the flow’, and able to respond to whatever comes our way. As coaches allow such a way of being our ability to ‘dance in the moment’ is maximized. We aren’t there to intervene, to fix things. We are not attached to a therapeutic agenda, to a treatment-oriented course of action. The client is in the lead and we are able to effortlessly dance with them.

Keeping It Client-Centered

At the heart of all coaching is the client-centered approach. From the psychotherapeutic roots of Carl Rogers this ‘person-centered’ way of interacting has become the basis for the coaching alliance.

“There have been parallels made regarding Carl Rogers’ person-centered theory and the way of doing nothing in Taoism (1). Rogers suggested that the most therapeutic counseling occurred when the therapist was authentic and real in the relationship and placed trust in the client to discern what was best for himself without interference from the therapist (2). A central concept of Taoism is doing nothing and being natural. Both Rogers’ theoretical beliefs and Tao philosophy maintain that when these conditions are achieved successfully in therapy, the human organism will develop almost spontaneously (3).”

An excellent review of this is found in “East Meets West: Integration of Taoism Into Western Therapy” by Rochelle C. Moss and Kristi L. Perryman. (4)

Coaches following these principles ‘get themselves out of the way’ and trust in the wisdom of their clients. We see our work as helping to bring forth, or evoke, the inner wisdom of our clients. When we are not attached to rigid protocols, yet operating out of grounded principles and methodology we can serve as guides to help our clients get to where they want to go.

Coaches and clients walk down a pathway together at night in the forest. The coach’s job is hold the flashlight and illuminate what is before them.

The client’s job is to choose how the path will be followed.

Neutrality allows the coach to operate without bias, without their own judgments and prejudices. This allows the client to be in the lead, making their own choices. This is where wellness coaches must adhere to the ethics of coaching and not be promoting their own products or particular courses favorite ways to eat, exercise, and so forth.

The highest virtue is to act without a sense of self
The highest kindness is to give without a condition
The highest justice is to see without a preference
Lao Tzu

Coaches who find value in the concept of Wu Wei see the value in yielding. In Western society yielding is often seen as failure, as giving up. Yet, some of the most storied successes on both Eastern and Western battlefields came because of strategic retreat. In wellness coaching this may take the form of allowing a client to set their own levels of accountability. For example a client may state that they can perform a certain behavior, such as walking, five times in the coming week. The coach may suggest that going from not exercising at all to doing so five times a week may be less likely to be successful. The client insists that they can hit this target of 5x/wk. The patient coach then allows the client to go ahead with their experiment rather than argue and let the client experience what the Adlerian psychologists would call natural consequences.

The power of yielding may also be something for our clients to discover. Often people approach situations with only one option in mind; to win! The wise person approaches any situation wanting to have all options at their disposal. In dealing with conflict, in managing stress, the option of yielding often pays off better than pushing for one’s initial desires.

At the heart of both the coaching process and Maslow’s theories of self-actualization and personal growth is the principle stance that human beings are inherently moving towards health and wholeness. With barriers removed and balance achieved, people will naturally make progress towards their highest good. The continually accumulating evidence from the Positive Psychology research substantiates this position. Such a way of looking at human beings and their experience in life is in complete alignment with Taoistitc principles of the interconnectedness of all things, synchronicity and the let it be attitude of Wu Wei.

The Centered Wellness Coach

Drawing upon what may be called “Philosophical Taoism” as opposed to any kind of religious or institutional Taoism, the wellness coach can find wisdom that does not necessarily contradict any other beliefs they, or their client may have. What we find is real alignment with the principles of growth and self-actualization that form the foundation of the wellness field. What we also find are very practical guidelines for practicing as an effective coach.

1. Practice What Centers You In Your Life
The wellness of the coach is the foundation all else is built upon. When we embrace whole-person wellness that includes, body, mind, spirit and our relationship with our environment, we practice a lifestyle that moves us towards optimal functioning. The key here is the word “practice”. Coaches are usually very caring people who place the needs of others far above their own. That can easily result in a lack of self-care, a neglect of the very well-living practices that we encourage in our clients. Find what “centers” you and practice it with regularity. Connect with friends, read novels, garden, hike, bike, walk, dance, meditate, do Yoga, Tai Chi, go fishing, enjoy your grandchildren, play with your photography or poetry, pray, volunteer at a non-profit, scrapbook, quilt, take your neighbor’s child for a day in the park. Do whatever gets your healthy needs met and gives you meaning and purpose.

When you get knocked off-center, accept how this is simply part of the normal human experience. The centered person does not tip-toe through life like they were on a balance beam. The idea is that of reducing our  “center-recovery time”. If we are practicing what centers us in our lives we can come back to center more quickly.

2. Practice effortless effort.
The primary mistake I notice when I observe coaching students who are learning the craft, is that they work too hard. The coach is working much harder than the client. When coaching does not go well it is usually when the coach is trying to make things happen. The coach is busy “fixing” the situation and/or the client, instead of facilitating the client doing their own work. The coach is busy attempting to convince or persuade the person to be well. The centered coach is patient.

3. Embrace Paradox
By trusting their coaching methodology, and by trusting their client the coach is able to offer a “coaching presence” that is: calm, yet lively; supportive, yet challenging; accepting and nonjudgmental, yet discerning; empathic, yet not colluding; compassionate, yet firm. Again, it is from this centered “stance” that such paradox can exist.

4. Know When To Push And When To Yield
We have a culture obsessed with “interventions”, with taking action. The Tao teaches us that there is a time for both action and non-action. I’ve observed coaches attempting to appear “powerful” by pushing for action whether the client is “ready” or not. When we use Prochaska’s Readiness For Change Theory we are actually acknowledging the reality of the energetic state our client is in. An old Gestalt Therapy expression is “Don’t push the river”. But, we also know the need to paddle when we are in a dead-calm lake! There is a time in coaching to forward the action through request. The Tao is as much about taking action as it is about pivoting and moving with no resistance. Again, the coaching metaphor of “dancing in the moment” means know when to push and when to yield.

5. An Effective Wellness Plan Is About Balance

A well-crafted wellness plan, co-created with our client would resemble the Yin/Yang symbol of Taoism. Ideally there would be as much involvement in active steps to build energy and there would be for more passive steps to help one relax, restore energy and achieve more balance. One side would balance out the other.

The reality is that as coaches we have been practicing The Tao of Wellness Coaching all along whether we called it that or not. Taoistic principles have already been infused in psychology, psychotherapy, business, leadership and more. Being more conscious in their application expands the coach’s repertoire of options and helps them nurture their own wellness as well.

References

1. Hermsen, E. (1996). Person-centered psychology and Taoism: The reception of Lao Tzu by Carl C. Rogers. The International Journal for the Psychology of Religion, 6(2), 107 – 125.

2. Hayashi, S., Kuno, T., M
orotomi, Y., Osawa, M., Shimizu, M., & Suetake, Y. (1998). Client- centered therapy in Japan: Fujio Tomoda and Taoism. The Journal of Humanistic Psychology, 38(2), 103-124.

3. Hayashi, S., Kuno, T., Morotomi, Y., Osawa, M., Shimizu, M., & Suetake, Y. (1994). A reevaluation of client-centered therapy through the work of F. Tomoda and its cultural implications in Japan. Paper presented at the Third International Conference on Client-Centered and Experimental Psychotherapy, Gmunden, Austria.

4. Rochelle C. Moss and Kristi L. Perryman
“East Meets West: Integration of Taoism Into Western Therapy”
https://www.counseling.org/resources/library/vistas/vistas12/Article_33.pdf taken from web 1.13.17)

Coaching a Client Through To A Mental Health Referral Using The Stages of Change

Times arise when it becomes apparent to a wellness coach that their client would benefit from working with a mental health professional. The need for referral may be urgent and involve client safety as when there is a threat of harm to self or others. That rare situation is usually more clearly recognized, referral is made and coaching is usually terminated. (“Top Ten Indicators to Refer a Client to a Mental Health Professional.” This can be found in the Wellness Resources section of the Real Balance website:https://www.realbalance.com/wellness-resources ) (See also this previous post: The Wellness Coach And Referring Clients To A Mental Health Professional: PART ONE – WHEN (http://wp.me/pUi2y-bA) )

More common is the situation where the client raises issues where there is no immediate danger or threat, but rather, there is either a history of unfinished emotional issues, or there are current circumstances that are creating barriers for the client’s effectiveness at succeeding at lifestyle improvement. In such situations, having a thorough working knowledge of the difference between coaching and therapy is essential for a professional coach. The best possible resource for this is this article by Meg Jordan and John Livingstone (https://www.realbalance.com/wellness-resources).

Resolution Vs. Relevance

How is the past affecting the present?

The first step would be for the coach to explore with the client to see if they are currently in therapy for these kinds of issues, or have been in the past. Then, the coach and client may be able to explore if they can coach about these issues, not to resolve them, but to see how they obstruct progress in the client’s efforts at lifestyle improvement. Can they be accounted for and worked with in coaching, or are the challenges so great that they will actually prevent progress in the coaching?

Well-trained coaches can do process coaching. The key here is to seek how the emotions of the client are relevant to the progress they are attempting to achieve in coaching. Perhaps a client repeatedly holds themselves back from engaging in the wellness/self-care activities that the coach and client create as action steps in their wellness plan. As this is discussed an internal barrier is identified that traces back to their family of origin. Perhaps a critical parent harshly enforced that all work must be done before one does anything for one’s self. Now, the goal of doing process coaching around this is not the resolution of all of the feelings and unfinished business with that parent (be they dead or alive). Instead, it is to gain insight regarding how these past learning’s are holding them back today. If the client is able to gain such insight and translate it into action (moving ahead with self-care) then the process coaching is achieving its goal. If the client continues to only process feelings and does not gain insight or does not succeed in shifting their behavior, then, we have probably identified an issue that is significant enough to warrant the encouragement of referral to a counselor or therapist.

In such cases or if the issues are beyond the scope of coaching and are interfering with client progress, then exploring making a referral needs to begin. How to make this referral successfully is not as simple as explaining the benefits of therapy and providing resource information. Very often clients are ambivalent, or even outright resistive to a referral to a mental health professional. The thought of reconnecting with all of the unpleasant emotion involved in working directly on their issues in therapy brings up fear. Unfortunately, coaches sometimes drop such a client quickly when they are not ready to jump into action and seek out the therapy they would benefit from. This is where a client would benefit from a coach who implements a Stages of Change approach (The Transtheoretical Model of Change developed by James Prochaska).

In the new book by James and Janice Prochaska Changing To Thrive (https://www.prochange.com/uncategorized/2017/02/prochaskas-new-book-changing-thrive-published), they make the point that most of the people we all work with are not in the action stage of change on any particular behavior. They estimate that only about 20% are actually ready to jump into action. Why would this be any different when it comes to engaging in counseling or psychotherapy? Yet, so often, when the client balks at following through on a psychological referral, coaching is abandoned. Instead, think of it as our job to help the person to weigh the pros and cons of engaging in counseling as they sit in the Contemplation Stage of Change. We are helping them with Decisional Balance. Taking a page from Motivational Interviewing, we coach as they work through their Ambivalence. We want to “roll with resistance” instead of accepting it as a rejection of our referral recommendation.

Coach THROUGH to referral!

Coach: So, I hear your hesitance when I suggest that counseling might be the best way forward with this.
Client: Well, yes. I’ve been in counseling before and I don’t know if I want to open up that whole issue again.
Coach: Sounds like you possibly have some fear about talking about such uncomfortable subjects again.
Client: Yeah. Growing up in my home was not a pleasant thing!
Coach: I know it holds a lot of negative memories for you. You’ve shared some stories about how bad it was. Yet, I also hear you saying that it’s frustrating to have these things hold you back from doing what you want to do today to be healthy and well.
Client: Right! It’s really frustrating! I know I need to get more active and take more time to eat right, but then I feel so guilty when I take time for myself.
Coach: So, on the one hand you really want to make these improvements to your lifestyle, but when you attempt to do so, these barriers, these thoughts get in the way.
Client: Exactly! I appreciate your help, but it seems like whenever we set up action steps, I never follow through on them, even though I know I need to.
Coach: Yes, we’ve explored how it’s all related, but we still seem stuck. What do you think would be the benefits if you did get back into counseling about this?
Client: Well, I guess I could really open up about it and try to unload some of this frustration. I’m just so tired of having the past hold me prisoner!
Coach: So a counselor could actually help you explore that and really make some progress in this area, perhaps result in some relief.
Client: Yeah. Okay. So what’s next?
Coach: Well, let’s work together on reconnecting you with some counseling. Let’s see what steps you can take to find the resources you need.

In this example the coach meets the client where they are. They help their client to Contemplate the idea of returning to counseling. Acknowledging the client’s fears and validating their feelings, the coach helps the client to begin to weigh the reasons to return to counseling and the reasons to avoid it. The family of origin stories are referenced, but not delved into. Instead, the emphasis is on relevance. How the past is getting in the way of the present is the essence of the contemplation. Then, at the end of the example we begin to move into the next Stage of Change; Preparation.

Coaching works because we are the client’s ally through the whole behavior change process. When referral comes up, we remain their ally. Then to help them actually follow through and make it to the referral resource, we help them with the process of identifying such resources, making the appointment, and attending the appointment. We offer support and accountability with all of the action steps required to achieve this preparation. We acknowledge the courage, the valuing of one’s self that is required for each step along the way.

James & Janice Prochaska with Michael Arloski

Take what you know about the Transtheoretical Model of Change (Stages of Change) and apply it to the referral process. Be your client’s ally when they need you the most.

 

SPECIAL ANNOUNCEMENT:  James and Janice Prochaska will be Dr. Arloski’s guests on the Real Balance Free Monthly Webinar – May 26 at Noon Eastern Time.  This will be a special one-hour webinar where the Prochaska’s will be sharing their breakthrough work from their new book CHANGING TO THRIVE.

“Changing To Thrive: Using the Stages of Change to Overcome the Top Threats To Your Health and Happiness” An Interview with James and Janice ProchaskaRegistration URL: Registration URL: https://zoom.us/webinar/register/bd820be2db187da1c5b9141539e44ee6

Nine Keys To Readiness For Change And Improving Your Lifestyle

Are we "ready" or are we "stuck" when it comes to change?

“People don’t change until they are ready to.”
James Prochaska

Lifestyle improvement is all about change, as we explored in our last post. When it comes to changing our thoughts, beliefs, and our behavior, the big question immediately becomes “How ready are you to change?”. The answer is not a simple yes or no, and extensive theories have arisen around this question.

The most important step for the person looking to improve their lifestyle (or the wellness pro helping them) is to ASK THE QUESTION: “How Ready Am I to Change?”. If we ignore the factor of “readiness” and forge ahead with a “call to action” we may just fall on our faces. The Transtheoretical Model of change (TTM) or “Stages of Change Theory” (best explored in Changing for Good, by James Prochaska, Carlo DiClemente, and James Norcross) dominates the wellness and health promotion field, as well as the addictions field, and for good reason. This model provides vital understanding of some fundamental aspects of change. For an excellent exploration of it in depth check out this great blogpost by Temple Univ. prof. Jonathan Singer: http://socialworkpodcast.blogspot.com/2009/10/prochaska-and-diclementes-stages-of.html

“Theory is extremely useful, because your theory determines what you can see.” Albert Einstein

I’ll be honest. When I first heard about Readiness for Change Theory and heard James Prochaska speak at The National Wellness Conference, I was not impressed. It seemed so simple and obvious that to bother stating it all in an elaborate theory hardly seemed worth the effort. “People don’t change until they are ready to.” Well, duhhhh! Then it hit me. Wait a minute. In healthcare, and all related fields, that’s not what we are saying to our clients and patients. We’re saying “Change now!” and completely ignoring looking at where they are truly at in this process of change.

As I became trained as a professional life coach I realized that the coaching field was ignorant of this theory as well. We were taught to “request action” much too early in the process. Today, competent life coach training schools such as The Institute for Life Coach Training (www.lifecoachtraining.com) and wellness coaching schools such as Real Balance Global Wellness Services (www.realbalance.com) have caught on and have integrated TTM into their curriculum.

“Change is a process, not an event.” James Prochaska

So what does “Readiness For Change” theory mean for the “man (or woman) on the street” who wants to improve their lifestyle? Here’s some basics to keep in mind as you work on change and growth.

1. There are six stages of change and it’s important to give each stage it’s due.
* Pre-contemplation – Haven’t even thought about change, am unaware of any need to change
* Contemplation – Am giving it some thought
* Preparation – Am preparing to change, finding out more information, checking resources and options
* Action – Actually making the change
* Maintenance – maintaining the change
* Termination (or Adoption) – the new behaviors/thoughts are part of me now, I don’t need to constantly “work at it”.

• 2. We can be at a different stage of change for each different behavior. I may, for example, be ready to start improving my activity level and improving my diet, but I’m not ready to quit smoking. Change is not a light switch. We aren’t as a whole person either “ready” or “not ready” to change.

• 3. The change process is often like a spiral staircase. We ascend up from pre-contemplation to contemplation and then to preparation, etc. We also can get discouraged, slip and spiral back down to earlier levels where we have to “pick ourselves up, dust ourselves off, start all over again” (to quote an old song).
• 4. Change is not just about will power and determination. It is a process that takes time to do right. Especially when we are talking about lifestyle behaviors that may have been in place for many years, just getting up a bunch of will power and thinking that we can suddenly change may be a very disappointing route to go. Instead see it as a process and give yourself credit for moving through each stage of change.
• 5. If you’re stuck at one stage, get an ally to help. The “forever-contemplating” or “forever-preparing” person may look like they are working on change, but the truth is they are stuck! Talk about it with people who you know will be supportive of your growth, not negative or pushing their own agenda of how you “should” change. Get a coach!
• 6. To maintain the change keep track of it! Taking action is great, but the key is maintaining it. I’ve had a number of wellness coaching clients tell me “I’m great at losing weight! I just can’t seem to keep it off.” Recording your new behavior, in someway that works for you, is a real secret of successful change. Don’t let it be a subjective estimation, get serious about self-monitoring and you’ll see more results.
• 7. Start where there’s motivation, readiness and likelihood of success. Don’t start climbing mountains by choosing the “Mount Everest” of your life first! Go for the more achievable and attainable goals where you are motivated to change first. Gain confidence and self-efficacy there and then take on the more challenging climbs.
• 8. Nothing succeeds like success! When you’ve achieved real progress in one area of your life, look at how ready you are now to improve your lifestyle in another area. Once you’ve seen success in being more active and eating better, take on getting more sleep or practicing relaxation training, etc. Take yourself through the Stages of Change from wherever you start, on up that spiral staircase.
• 9. No model has it all figured out. Even the much-revered TTM has it’s critics. We don’t always go through these stages of change in a nice neat manner. Sometimes change does happen as what seems like an event! We’ve all seen times when circumstances and motivation peaked and “cold turkey” success was achieved with great pride! So no single model can explain this incredibly complex phenomenon of change.

We’ll continue to explore more about what it takes to improve your lifestyle and succeed at change in future posts. We’ll also explore other areas of wellness and keep it grounded in what can really make a difference in your life.

“I don’t want to hear any philosophy that won’t grow corn.”
Sun Bear, Native American Teacher