Hance, Billie Jo B.S.; Moore, Margaret M.B.A.
In its 2006 white paper, Wellcoaches Corporation refers to the nation's obesity epidemic as "a crisis of confidence" and explained that when it comes to pursuing optimal health, people become mired in the muck of chronic contemplation and negativity, sometimes for decades (4). This article describes the Wellcoaches coaching model, which draws on many domains of psychology, and the insights and experiences of physicians, academics, coaches, fitness professionals, dietitians, and clients. A valuable coaching tool, Mount Lasting Change captures the change or developmental process where people outgrow old lifestyles. The tool grew out of the well-researched Transtheoretical Model (TTM) of behavior change and evolved to reflect the work of coaches as they help clients navigate the path to lasting behavior change. This article provides techniques, such as observations, coaching questions, and positive reframing, that health professionals can envision as a metaphoric hike: to the summit of Mount Lasting Change (8).
Although people's actions (e.g., going on a diet, joining a gym) may suggest that they are ready to change, they may not signal a true commitment to permanent behavior change, according to Wellcoaches findings. Says behavioral psychologist Gabe Highstein, whose work has focused on training coaches to recognize participants' stage of change and deliver appropriate interventions based on stage of readiness, "There's a bit of cognitive homework that needs to go on first" (G. Highstein, oral communication, 2006). Indeed, most trainers have witnessed the "New Year's resolution" behavior of clients, whose initial energy fades into canceled sessions. And doctors know that their annual advice to patients to lose weight and exercise does not typically lead to change.
Mount Lasting Change (Figure 1) is a model for coaching clients to successful behavior change. As MapQuest or Google Maps outline the steps between our home and our destination, the building blocks of the mountain help physicians and fitness professionals identify where people are in their change process, meet them there, and engage them in cognitive and behavioral work that is the foundation for lasting change. Once that base is established, clients can make progress toward realistic improvements in health and well-being.
Mount Lasting Change draws from the research on behavior change led by the behavioral psychologists Prochaska and DiClemente (5). The TTM focuses on a person's decision-making process, rather than outside influences of behavior. It has been widely used to help people change in areas such as smoking, weight control, exercise, alcohol abuse, and stress management (6).
THE "EXPERT" PARADOX
Physicians and fitness professionals routinely and appropriately give advice to their patients and clients, drawing on their expertise and experience; clients and patients come to them presumably because they are experts. But there is a downside to the expert approach: patients and clients may perceive the subtle message: You are not in charge. The expert approach of taking charge and telling people what to do "fosters the lack of confidence people already feel," and paradoxically, can foster low self-efficacy ("I can't really do this") (4).
Edward M. Phillips, M.D., assistant professor at Harvard Medical School, believes that physicians can play a vital role in deepening patients' motivation to take responsibility for enhancing their wellness (E. Phillips, M.D., oral communication, 2006). Phillips works with patients to connect their medical history to their current behaviors and then to what they treasure most in life. A conversation he relates with one of his patients, a sedentary overweight fireman on three different medications, illustrates both the pitfalls in making assumptions about a patient and the power of intuitive questioning and reflections.
Phillips: So, it sounds as though you don't have time to exercise.
Patient: No, I have all kinds of time. The fire trucks can only be so shiny.
Phillips: Perhaps you don't have access to a facility?
Patient: No, we have a treadmill and weights in the firehouse.
Phillips: Well, would you feel foolish being the only one working out?
Patient: No, actually, I'm the only one who doesn't exercise.
Clearly, the patient did not have the usual obstacles to exercising regularly. So, Phillips took the conversation in another direction:
Phillips: If I could give you one prescription that would help you avoid your mother's diabetes and your father's stroke while reducing or eliminating your medications, would you be interested?
Patient: Of course.
When he helped his patient connect a family history of disease to his own behaviors, a light bulb went on. Says Phillips: "That was compelling to him. He didn't want to have his parents' health profile - he wanted to be much healthier as he got older."
Phillips' interactive presentations to physicians encourage them to integrate behavior change concepts into their interactions with patients. At the same time, he challenges physicians to ask themselves when they last attempted a change that affected their own health. "What made you fall off the wagon?" he asks a pediatrician who dieted and exercised for her daughter's wedding and then stopped shortly after. She responded, "I wasn't clear what I was doing and my husband didn't like the food and I was bored…." In other words, once she had met her goal of looking good for the wedding, she predictably discontinued exercising and dieting. Phillips' work confirms that by finding a deeper personal value, such as setting an example for her patients, she would likely be more committed to sustained lifestyle changes.
Behavioral research points to the notion that what moves us from contemplation of a healthful behavior to action is linking our actions to our values - why we value being fit and well at a deep level (Figure 2). When we lose external motivation (e.g., when the wedding is over), we need to reconnect with a deeper meaning as well as tap into our personal strengths to stay on track.
CLIMBING THE MOUNTAIN IN PRACTICE
All health care professionals can integrate powerful but simple coaching strategies into their relationships with patients and clients by capitalizing on the unique values and strengths that each client possesses. Coaching can catalyze and reinforce deep motivation and build confidence by brainstorming strategies to avoid lapses. Adding coaching to the mix does not require abandoning the critical role of providing expert guidance, but rather acknowledges that people change from within-not simply in response to information provided within the typical heirarchy of the expert/patient interaction. Tobacco use proves the point: If information alone was sufficient to change behavior, no one would smoke because everyone who smokes has read the Surgeon General's warning that appears on every pack of cigarettes.
Helping clients "climb the mountain" requires a challenging shift from telling to asking; from knowing (the facts) to being comfortable not knowing (the client's thoughts); from selling solutions to struggling clients to supporting them to think hard and find their own way; from not only helping clients recognize and build on the strengths they already have, but also helping them cultivate new and unfamiliar strengths.
THE VISION LEVEL - DEVELOPING A SOLID BASE FOR CHANGE
The base of the mountain is a compelling vision. This is where the client begins to gain greater self-awareness, as well as an understanding of both the benefits of change and the obstacles.
At the vision level, we explore why we want to change in the first place. In the words of Dr. Phillips, simple questions such as "what's in it for me?" encourage patients to find the personal motivation that is the basis for all change: "If we move to the Action level without the work to develop a vision and a plan, when we fall, we fall too far" (Figure 3).
Nonjudgmental interest and curiosity catalyzes the client or patient to look internally and start doing the thinking work that supports change. A warm and empathetic way of being not only shows that someone cares about them, but encourages clients to accept themselves and let go of the past, a precondition for moving forward.
Personal trainer and wellness coach Ellen Goldman encourages her training clients to dig out their core values by asking them to write down 15 reasons why they want to get in shape. After they list each one, she asks them to answer the question "What's so great about that?" The client who has made a New Year's resolution may eventually drill down to the desire to be healthy enough to play with her growing grandchildren, which connects her with her core life values. Goldman comments, "With 15 reasons, they usually get a little deeper and begin to draw on their motivation. Or, they find they really aren't all that motivated right now-and that's OK, too" (E. Goldman, oral communication, 2006).
Connecting clients and patients with their strengths helps them overcome the negative self-talk that often accompanies efforts to change. Harvard psychologist Carol Kauffman, Ph.D., director of the Institute of Coaching at McLean Hospital, affiliated with Harvard Medical School, suggests redirecting clients toward their existing strengths to help them turn their wellness visions into reality. "Instead of focusing on skill deficits or a client's dissatisfaction," says Kauffman, "the practitioner can choose to shift attention away from pathology and pain and direct it toward…strength, vision, and dreams" (2).
Goldman finds that challenging a client to develop solutions, rather than supplying them herself, has an immediate impact on the client's sense of self-efficacy. She cites an example of a client who consistently asked her advice about what to eat on the weekend and then just as consistently failed to follow the advice. Says Goldman, "Finally, I just asked her, 'What do you think will be challenging about your weekend? What can you do that would make that a little less challenging?'" The client came up with her own successful strategies - and later thanked Goldman for the ideas. "She was amazed when I told her she had thought of them, not me!" remarked Goldman. Using coaching strategies with her clients, Goldman consistently finds that "when it becomes their idea, they own it and are excited to do it" (E. Goldman, oral communication, 2006).
Helping clients reconnect with their own track record of accomplishing difficult tasks helps them gain the self-efficacy they need to move forward. If they remind themselves that they have successfully completed graduate school, raised a family, or achieved careers goals, they are more likely to see healthy behavior change as less daunting.
For some clients, taking responsibility can occur at the moment when they "get that it is up to them to make the necessary changes to achieve what they want," says coach/trainer Debbie Keifiuk. Although many people look to professionals to keep them motivated, those who take responsibility for their change find that motivation within. "Having clients dependent on trainers fails to enhance self-efficacy and self-esteem. A masterful trainer is one who does not want his or her clients to be dependent on him or her" (3).
THE PREPARATION LEVEL - CLIMBING OUT OF NEGATIVITY
In the preparation level, says Highstein, "one foot is in contemplation and the other one is trying out action." Trainers and physicians frequently hear negative statements such as "I'm lazy," "I'll never be able to get to my goal weight, I've been this way for years," and "It's easy for you - you do this for a living." A common, and generally ineffective, response to such statements is to encourage and cheerlead, which often sounds hollow and pro forma to the client. An alternative is to encourage clients to focus on what they want - the positive outcomes of their behavior change - not on what they don't want (e.g., "I don't want to get diabetes"). Generating their own positive emotions and a positive mindset spurs them to continue on the mountain climb.
Encouraging a client to talk about what he or she did that was positive that day or week can foster confidence and increase self-efficacy. Goldman attests to the challenge of this strategy, citing clients who on Monday morning cannot stop talking about how "bad" they were over the weekend. When they can't come up with one positive thing about themselves, she observes, "Well, you showed up at my door this morning, right?" (E. Goldman, oral communication, 2006).
THE ACTION LEVEL - BEHAVIORS RATHER THAN OUTCOMES
The third level on the way to the top is "doing" (specific behavioral goals). Early "wins" and ongoing fine tuning are critical. Helping clients to keep going, and not fall back to contemplation, is a major challenge. One measure a coach can take is to help clients set reasonable, measurable goals that can be completed in a short period. Executive wellness coach Pam Schmid encourages clients to change the metric from outcomes to specific behavioral goals. A detailed plan of putting their vision into action is critical. Saying "I want to lose 10 pounds" doesn't say how it will happen. When clients focus on the behaviors to get there, success is more probable. When they think, "What is it I need to be doing on a consistent basis?" they learn how to think about the steps it takes to reach a goal or vision (7).
Brainstorming and problem solving are important steps in clients' behavior change efforts in the implementation phase. Challenges and setbacks are necessary and welcome friends and teachers on the path to lasting change. Integrating new behaviors into a life without first making room for them is next to impossible for even the most committed person. Both physicians and fitness professionals can ask simple questions to clients to help them think about how they will integrate new behaviors into their already busy and hectic lives. Phillips likens the process to artificial intelligence: "You try and learn from your mistakes, making midcourse corrections, bouncing back, and improving your performance as you go."
Celebrating the early wins from new habits is essential. We can ask our clients how they will feel better and reward themselves when they reach their goals, as well as keeping track of their goal progress, so that we can acknowledge them and celebrate with them. When clients want to reward themselves in ways that reinforce old patterns, Phillips suggests asking what other rewards might foster a sense of accomplishment. Coach/trainer Claire Denise says her client "decided on an alternative reward - to buy new workout clothing - for each 10 lbs lost, when previously she rewarded herself with food" (1).
THE RESULTS LEVEL - PLANNING FOR RELAPSE
The saying goes "If you fail to plan, you plan to fail." People who have successfully integrated a new healthy habit are often torn between two opposite poles: believing that they will inevitably relapse and fail, or being afraid to think about relapse for fear of jinxing the process. By explicitly addressing these, the cloud of fear of relapse lifts. Preparing for relapse and brainstorming with clients about how they will respond if they start to slide helps them to avoid getting caught off guard. Trainers also can take note when someone has not been in the gym for a week and call to provide support and nonjudgmental feedback for clients who have lapsed.
Phillips believes that continuously revisiting the base of the mountain is the best insurance against prolonged relapse. "When we build the vision level, it cushions us when we have lapses by reminding us of our values. What keeps us going in the long run is to access and stay connected to what we value most" (E. Phillips, M.D., oral communication, 2006).
BECOMING OUR BEST SELVES
Although the physical changes and increased confidence are valuable outcomes of behavior change, what clients yearn for most is to be their best. Celebrating their successful navigation of the change process and appreciating their determination and willingness to meet challenges bring to life their best selves. Linking their changes back to their original motivation, values, and vision, reinforces and expands their best selves: just what's needed as they continue on life's journey.
CONDENSED VERSION AND BOTTOM LINE
As experts, health professionals all too often unwittingly feed into their clients' sense that they cannot manifest their own positive changes. The research in behavior change suggests that a more successful approach is to encourage clients to take charge by getting in touch with their intrinsic motivators, setting small reasonable goals, reframing energy-draining negative self-talk to motivating positive messages, and planning for lapses. Coaching methodology can be used by physicians, personal trainers, and other health professionals to encourage clients to find their own solutions, to recognize and build on their strengths, and to cultivate new and unfamiliar strengths. Mount Lasting Change provides a valuable and easy-to-use tool to assist health professionals engage their clients in the cognitive and behavioral foundations for powerful lasting change.