Lifestyle Medicine Competencies

Lifestyle Medicine CompetenciesAdvanced Curriculum

Coaching (2.5 CME Hours)

Developing Growth-Promoting RelationshipsMargaret Moore, MBA

Learning Objectives

• Describe how to create relationships with patients which foster their personal growth

• Apply effective coaching techniques for relationship-building

Medicine is designed for acute not chronic care

Lasting change requires changing mindsets + behaviors

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Adults are not thriving…..reducing resources to support change

and resilience■ 80% are not thriving mentally■ 95% don’t engage in top 5

health habits■ 70% aren’t engaged in work■ 58% report being addicted to

cell phones

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Our brains learn by making new connections and building new networks.

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Neuroplasticity can be described as an iterative process over weeks and months:

Insight to action to insight to action to insight…

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Coaches Catalyze Insights

People are generally better persuaded by the reasons which they have themselves discovered, than by those which have come into the mind of others. Pascal’s Pensees, 17th century

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Coaches See the Butterfly in the Chrysalis

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Coaches are inspiring role models.Physician John Principe in his teaching kitchen.

www.wellbeingmd.com

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http://www.wellbeingmd.com

Definition of Health and Wellness Coaching

Health and wellness coaches facilitate a partnership and change process that enables clients to change their mindsets, and develop and sustain behaviors proven to improve health and well-being, going beyond what they have been able to do alone.

Coaching improves:• Self-awareness• Autonomy and personal responsibility• Self-motivation• Self-confidence• Self-regulation• Resilience

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Expert Approach Coach Approach

• Authority• Educator• Defines agenda• Feels responsible for client’s

health• Solve problems• Focus on what’s wrong• Has the answers• Interrupt if off topic• Working harder than client• Wrestle with client

• Partner• Facilitator of change• Elicits client’s agenda• Client is responsible for health• Foster possibilities• Focus on what’s right• Co-discover the answers• Learn from client’s story• Client working as hard as

coach• Dance with client

Growth-Promoting Relationships

• Coaching frame of reference• Mindfulness• Elicit self-compassion• Listening, Reflections, Open Inquiry• Coaching presence• Roll with resistance

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Coach’s Frame of ReferencePeople are generally better persuaded by the reasons which they have themselves discovered, than by those which have come into the mind of others.Pascal’s Pensees

Get out of sales and into fishing. Robert Rhode, PHD

I saw an angel in the stone and I carved to set her free.Michelangelo

When a client has a good coach, he says, “Wow my coach is good!”When a client has a great coach, he says, “Wow I’m good!”

Activate Mindfulness • Take three deep breaths• Close eyes for five seconds • Become aware of your breathing

What can you say to yourself:• I am grateful for this opportunity to connect

and make a difference• I have an opportunity to make a pivotal

contribution• I am open to and curious about what will

unfold

Mindful Openness & Presence

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Mindful Listening

• Non-judgmental awareness of what patient is saying

• Not thinking about what I will say next• Weaving patient’s last words into the next

step• Weaving the patient’s story into later steps • Pausing before responding • Listen for emotions as well as facts• Not interrupting

Listen for Emotions

• The limbic system often knows the truth before the prefrontal cortex.

Show Compassion

• I am warm• I am patient• I accept you• I am working to understand what it is like

to walk in your shoes• I am not judging you• Our agenda is only your agenda

Outcomes• Creates trust and rapport• Helps people accept themselves• Defuses resistance

Physician Empathy Improves Clinical Outcomes

ConclusionsPatients of physicians with high empathy scores were significantly more likely to have good control of hemoglobin A1c (56%) than were patients of physicians with low empathy scores (40%, P .001).

The proportion of patients with good LDL-C control was significantly higher for physicians with high empathy scores (59%) than physicians with low scores (44%, P .001). Hojat M. Academic Medicine. 2011; 86(3):359-363.

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Foster Self-CompassionBasic Biology for Negative Emotions

Use Your Hands to Change Your Brain State

Inner CriticPress finger nails into palms

Self-CompassionAcceptance

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Open-Ended Questions

• Cannot be answered by a simple yes or no• What and How questions• Positive, curious questions in a non-

judgmental tone• Elicit your patient’s story• Why questions can sound judgmental and

feel like an interrogation• The one place where WHY questions work:

Why does being healthy matter to you?• One place for a closed question:

Are you willing to commit…

Value of Reflections • Clients hear what they are saying• More provocative and transformational than inquiry• Reflections create connection • Reflections tap into emotional state

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Types of Reflections

• Simple - Restate exactly what the client said

• Empathy – Reflecting the feelings and needs that have been expressed

• Clarifying – An in-the-moment check in: What I hear you saying is…What you’re saying is…

• Amplified - Used to provoke emotion in either a positive or negative direction

• Double-sided - Reflect both a pro-change statement and resistant statement the client has made

• Summarizing – A summary statement of what’s been said

Silence

W.A.I.T. ---- Why Am I Talking?

Physician Communication & Weight Loss in Adults

No differences in weight loss were found between patients whose physicians discussed weight or did not.

Patients whose physicians used motivational interviewing–consistent techniques lost an average of 1.6 kg 3 months post-encounter; those whose physician used motivational interviewing–inconsistent techniques gained or maintained weight.

Conclusions: Use of motivational interviewing techniques during weight loss discussions predicted patient weight loss.Pollak K I. Am J Prev Med. 2010; 39(4); 321-328.

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Coaching Presence• Empathy - Understanding how the other

feels, warmth, patience, acceptance, affirmation

• Calm - Presence, calm-energy, sense of purpose, quiet confidence

• Zest - Alive, energetic, vital, spirited, sense of adventure

• Playfulness - Humor, curiosity, playful recognition, enjoyment, creation of incongruities, find a light and cheerful view of adversity, make others laugh

• Courage and authenticity - Speaking the truth with love, mastery of fear, honesty, and willingness to risk a wrong step

Which come naturally for you? Which need more attention?

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Voice – Use it for maximum impact

• Be mindful• Be empathetic• Be calm• Be energizing• Be playful• Be courageous

Roll with Resistance

• Compassion– Don’t resist resistance – it’s a signal to

change dynamic– No judgment, no agenda, complete

acceptance– Use lots of reflections– Get onto client’s side of the change fence– Validate reasons not to change

• Explore– Look for “cracks” to explore reasons to

change– How can I help you today?

1. Be mindful and present2. Practice listening, inquiry, reflections3. Don’t think about what you are going to say

next4. Listen, reflect, and show compassion for

emotions5. Balance open-ended questions with reflections6. Have patient speak more than you do7. Catalyze insight

Relational Coaching Skills Summary

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Lesson Questions

• What are the main coaching skills that build trust and rapport?

• What is the impact of physician empathy?

• What are the main differences between the expert approach and the coach approach?

Practice Processes for Improving Outcomes

• Investigate training yourself and your team in methods to improve patient relationships through mindfulness, empathy, listening, and patient insight generation.

Tools and Resources for Health Behavior Change

This presentation is based upon coach education and training programs developed by Wellcoaches Corporation, in partnership with the American College of Sports.

Other Resources1. Coaching Psychology Manual, Lippincott, Williams &

Wilkins, 20102. How Coaching Works, YouTube3. Organize Your Mind, Organize Your Life, Harvard Health

book, 20124. Motivational Interviewing, 3rd Edition, 2012

Lifestyle Medicine CompetenciesSelf-Motivation & Self-Confidence

Margaret Moore, MBA

Learning Objectives

• Describe the role of self-motivation and self-confidence in effective coaching for health behavior change

Science of Motivation: University of Rochester

Ed Deci, PhD Rich Ryan, PhD

Ryan RM, Deci EL. Self-determination theory and the facilitation of intrinsic motivation, social development and well-being. American Psychologist. 2000: 55, 68-78.

Science of Self Efficacy

Albert Bandura, PhD James Prochaska, PhDStanford University University of Rhode Island

Bandura, A. Social foundations of thought & action: A social cognitive theory, 1986Prochaska, James O., Norcross, John C., & DiClemente, Carlo C. Changing for Good: A revolutionary six-stage program for overcoming bad habits and moving your life positively forward, 1994

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Science of Motivational InterviewingBill Miller, PhD Stephen Rollnick, PhD

Rollnick S and Miller WR, Motivational Interviewing, Helping People Change, (Application of Motivational Interviewing), 2012; Rollnick S, & Miller, WR. What is motivational interviewing? Behavioural and Cognitive Psychotherapy, 1995; 23, 325-334.

Motivation Topics

Vision Autonomous motivation Values, Purpose, Meaning Decisional balance

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Imagine the Desired OutcomeWe are drawn toward an appealing vision of our ideal future, like a

flower drawn to the sun.

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Autonomous Motivation• Present – I’m cleaning up the kitchen

because it’s fun and challenging• Future – I’m cleaning up the kitchen

because it makes me feel good about my contribution to my marriage and family

External• Inner critic – I am cleaning up the kitchen

because I should – I will feel like a bad husband if I do not

• Expert – l am only cleaning up the kitchen because my wife will be angry if I don’t

Motivation Types: Why am I cleaning the kitchen?

Autonomous Motivation• Present – I’m cleaning up the kitchen

because it’s fun and challenging• Future – I’m cleaning up the kitchen

because it makes me feel good about my contribution to my marriage and family

External• Inner critic – I am cleaning up the kitchen

because I should – I will feel like a bad husband if I do not

• Expert – l am only cleaning up the kitchen because my wife will be angry if I don’t

Which motivation type predicts sustainable change?

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All the greatest and most important problems of life are fundamentally insoluble… They can never be solved, but only outgrown. This “outgrowing” proves on further investigation to require a new level of consciousness.

Some higher or wider interest appears on the horizon and through this broadening of outlook the insoluble problem loses its urgency. It is not solved logically in its own terms but fades when confronted with a new and stronger life urge.

Carl Jung

Motivation emerges from one’s Life Force

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Coaching Questions Value, Purpose, Meaning

Health and well-being are the means not the end, the fuel source for the lives people want to live.

1. What do you treasure most about your health and well-being?2. How does your health allow you to live your best life, reach your

vision, or be your best self?

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A decisional balance addresses various needsor drives around change

ConsReasons to Stay the Same

ProsReasons to Change

Resistance Score Motivation Score

Benefits of changeConcerns about change

Concerns about staying the sameBenefits of staying the same

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Importance (motivation) and confidence together determine readiness to change for a

specific habit

Precontemplation

Contemplation

Action

Preparation

Maintenance

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Build Self-ConfidenceDevelop Capacity to Change

Elicit and harvest positive emotions Leverage strengths Develop supports Just-in-time learning Improve self-efficacy

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Increase positive emotions to increase brain function, resilience, & health

• Positive emotions are fleeting• Negative emotions stick like VELCRO

• Positive emotions broaden thinking– flexibility, creativity, open-mindedness

• Positive emotions build resources– mental, physical, psychological, social

• Ideal ratio is 3:1 positive to negative• What’s your ratio? www.positivityratio.com

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http://www.positivityratio.com/

• Past – forgiveness, gratitude, satisfaction• Present - savoring, mindfulness,

Engagement and flow, meaning, gratitude• Future – hope, vision, positive anticipation,

optimism

The endeavors which bring the highest level of life satisfaction are those where we engage our strengths, stretching to the edge of our abilities, for a higher purpose.

Martin Seligman, PhD, Authentic Happiness

Positive Emotions & Time Perspective

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Character StrengthsOnly 1/3 of adults know their strengths.

Using one’s strengths and talents improves confidence.

Wisdom and knowledge: creativity, curiosity, open-mindedness, love of learning, perspective

Courage: authenticity, bravery, persistence, zestHumanity: kindness, love, social IntelligenceJustice: fairness, leadership, teamwork Temperance: forgiveness, modesty, prudence, self-regulationTranscendence: appreciation of beauty, gratitude, hope,

humor, religiousness

www.viacharacter.org

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Character StrengthsPersistence and Self-Regulation rank lowest among US

adults, making change difficult for many.

Wisdom and knowledge: creativity, curiosity, open-mindedness, love of learning, perspective

Courage: authenticity, bravery, persistence, zestHumanity: kindness, love, social intelligenceJustice: fairness, leadership, Teamwork Temperance: forgiveness, modesty, prudence, self-regulationTranscendence: Appreciation of beauty, gratitude, hope, humor,

religiousnesswww.viacharacter.org

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Apply Strengths to Build Confidence

• Learn from successes in all facets of life• Celebrate what is going well made possible by one’s

abilities• Leverage strengths - www.viacharacter.org• Leverage talents – www.strengthsfinder.com,

www.strengths2020.com

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Coaching Exercise: Apply Strengths

Help patients constantly look for and apply strengths that have been used elsewhere in their lives.• What are your top five strengths?• Explore how to use a strength to help you reach your

vision?

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Coach the Environment

• Environment – What needs to be in place• People - Recruit support team• Things/Structure – What could serve as a reminder

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Just-in Time Learning

• We are in information overload• Health and wellness info is overwhelming and contradictory• What skills and knowledge are needed right now?

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Just-in Time Learning• Don’t make assumptions about what patient knows or

doesn’t• Ask permission before you share information or ideas• NOTE: Any information that is critical to health or safety

must be shared

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Creativity - BrainstormEnter a defocused state of attention that allows you to see the connections between objects or concepts that are quite disparate in nature. You and your patient generate multiple solutions to a given problem rather than focusing on a single solution.

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Coaching Exercise: Creativity

• What challenge do you want to explore?• Creative Brainstorm – identify at least three new

strategies to increase hope and confidence

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Summary: Coaching Tools to Build Self-efficacy

• Start with area/behavior in which client has confidence (not the guidelines…)

• Leverage strengths• Cultivate positive emotions• Avoid all or nothing thinking• Match skills with challenge• Use creativity to overcome challenges• Set realistic, behavioral goals• Adopt the mindset of a self-scientist – no

failure, only learning• Explore, validate, and celebrate success

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Lesson Questions

• What is the type of motivation that works best in sustaining health behavior change?

• Name three ways to help patients build confidence.

Practice Process for Improving Outcomes

• Implement approaches to build patient:– Self-awareness– Self-motivation – Self-confidence– Readiness to change


This presentation is based upon coach education and training programs developed by Wellcoaches Corporation, in partnership with the American College of Sports Medicine.Other Resources1. Coaching Psychology Manual, Lippincott, Williams & Wilkins,

20102. Motivational Interviewing, 3rd Edition, 20123. Your Creative Brain, Harvard Health book (2010)

Lifestyle Medicine Competencies

The Coaching ProcessMargaret Moore, MBA

Coaching Learning Objectives

• Describe the main stages of the coaching process.

• Learn coaching questions for each stage.

Agenda

• Science, Art, Coaching• Vision• Preparation• Action• Results• My Best Self• Celebrate!

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RECALL from Lesson 3:Expert Approach Coach Approach

• Authority• Educator• Defines agenda• Feels responsible for

client’s health• Solve problems• Focus on what’s wrong• Has the answers• Interrupt if off topic• Working harder than

client• Wrestle with client

• Partner• Facilitator of change• Elicits client’s agenda• Client is responsible for

health• Foster possibilities• Focus on what’s right• Co-discover the answers• Learn from client’s story• Client working as hard as

coach• Dance with client

Changing for Good

No problem can be solved from the same level of consciousness that created it. We must learn to see the world anew.~ Albert Einstein

One cannot understand a level of consciousness above one’s own.~ Robert Kegan, In Over Our Heads

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Mount Lasting Change

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Vision Level

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Self-Determination: Why We Do What We Do

• Autonomy – find one’s own motivation• Authenticity – marching to own drummer• Intrinsic motivation – higher learning, creativity,

performance, and success

Given the right conditions, we are self-determining beings!Ed Deci & Rich Ryan

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Responsibility & Self-Discovery

• Autonomy – People choose what, when, and why to change when they are ready, willing, and able.

• Taking charge and taking personal responsibility for change is our call to action.

• Internalizing responsibility rather than blaming external forces.

• Developing a curious and mindful self-awareness• Self-empathy and forgiveness is a springboard• I am unique

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You have brains in your head.You have feet in your shoes.You can steer yourself any direction you choose.You're on your own.And you know what you know.And YOU are the one who'll decide where to go!~ Dr. Seuss

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Human beings, who are almost unique in having the ability to learn from the experience of others, are also remarkable for their apparent disinclination to do so.~ Douglas Adams

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Nothing can stop the man with the right mental attitude from achieving his goal. Nothing on earth can help the man with the wrong mental attitude. ~Thomas Jefferson

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In the long run, we shape our lives, and we shape ourselves. The process never ends until we die. And the choices we make are ultimately our responsibility.~Eleanor Roosevelt

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The mind is like a parachute - it works only when it is open.~ Frank Zappa

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One’s own self is well hidden from one’s own self:Of all mines of treasure, one’s own is the last to be dug up.~ Friedrich Nietzsche

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Coaches get into the passenger’s seat, and ask patients to get into the

driver’s Seat. Coaches resist the urge to grab the steering wheel.

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Responsibility: Coaching Inquiry

• What will it take for you to be in charge of your own lifelong journey to higher well-being?

• How can you move beyond looking for the next quick fix where you hand over control to somebody else?

• How can you be at peace with the past, appreciate it’s lessons, and take charge of the present and future?

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Strengths

• Using strengths elicits intrinsic motivation• Engaging strengths is energizing while engaging

weaknesses is draining• Applying strengths builds confidence• Applying strengths improves performance• Applying strengths builds positive emotions and

resilience

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Strengths

Don’t let what you cannot do interfere with what you can do.~John Wooden

Leaders build on strengths, making weaknesses irrelevant. ~Peter Drucker

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Strengths: Coaching Inquiry

• How do you use your strengths in life and work?• What strengths can you use to support your change

journey?

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Values & Purpose• This building block is at the center of the foundation

because it represents the higher purpose and deeper meaning for change.

• Connecting to our values and purpose are the motivational fuel that keeps us going in the face of big and small challenges.

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Self-Determination: Motivation Types• External regulation - low investment• Introjected regulation - self-imposed

related to self-esteem – motivation unstable• Integrated regulation - done for the sake

of outcome• Intrinsically motivated - behaviors that

are exciting, interesting, and performed for satisfaction alone

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Values & Purpose

The thing always happens that you really believe in; and the belief in a thing makes it happen.~Frank Lloyd Wright

You can’t wait for inspiration. You have to go after it with a club.~Jack London

People always say "Motivation is great but it doesn't last." I just tell them, bathing does not last either, that is why I recommend it daily.~ Zig Ziglar

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Values & Purpose: Coaching Inquiry

• How does your health and well-being serve what you treasure most or your life purpose?

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What optimizes my physical health?

Awareness, Knowledge, and Engagement THREE PILLARS OF BQ

Body Intelligence: BQ

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Body Intelligence

The most difficult thing in life is to know yourself.~Thales

There are three things extremely hard: steel, a diamond, and to know oneself~ Benjamin Franklin

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Body Intelligence: Coaching inquiry

• How aware are you of the signals that your body and brain send you about how well they are functioning?

• What do you know about what makes your body and brain work optimally?

• What new knowledge do you need now (just-in-time learning)?

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Decisional Balance

Cons Reasons to Stay the Same

ProsReasons to Change

Resistance Score Motivation Score

Benefits of changeConcerns about change

Concerns about staying the sameBenefits of staying the same

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Challenges

• Identifying, illuminating, and fully exploring major challenges, such as competing priorities, lack of time, lack of confidence, and the benefits of not changing, are critical ongoing processes.

• Raising awareness of how impediments both serve us and limit us is important thinking work.

• Challenges are often a sign that our mindset needs to grow.

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Strategies

• After enumerating big challenges, employing realistic strategies to overcome these barriers follows.

• Can’t move forward to prepare for change unless we have articulated strategies to deal with our challenges –strategies that we are confident will work.

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Challenges & Strategies

Nothing is predestined: The obstacles of your past can become the gateways that lead to new beginnings. ~ Ralph Blum

If you find a path with no obstacles, it probably doesn't lead anywhere.~ Frank A. Clark

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Challenges & Strategies: Coaching Inquiry

• What is your major challenge and how can you deploy your strengths to overcome it?

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Vision: Summary

• I am in charge and curious about learning about myself.• I have the strengths needed to be successful.• What I treasure most and my life purpose are my

motivational fuel.• I am mindful and improving my body intelligence

(awareness and knowledge).• I understand my challenges and have strategies to

overcome them.

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Vision

You must begin to think of yourself as becoming the person you want to be.~David Viscott

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Vision of Best Self

• What is your vision for your health and well-being?• Who is your Best Self when it comes to your health and

well-being?

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Up We Go: Preparation Level

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Goals + Plan

• Developing and updating a detailed plan describing schedule, preparation, as well as clearly defining the behavioral goal (what, when, how) is critical.

• Tracking our performance is also important– use journals or logs to record what we eat, our

exercise bouts, or relaxation activities.

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Goals & Plans

Before anything else, preparation is the key to success. ~ Alexander Graham Bell

If you don't know where you are going, you'll end up some place else. ~ Yogi Berra

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Goals & PlansThe most important thing about goals is having one.~ Geoffry Abert

A good plan today is better than a great plan tomorrow.~ George Patton

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Goals & Plans: Coaching Inquiry

• Where would you like to be three months from now –what new habit(s) are you ready to develop – and how will you get there?

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Support

• Support from family, friends, colleagues or health care professionals helps us work through the tough phases of the change process.

• Cultivate nourishing relationships that meet the needs of both people to give and receive support.

• Design our environments to support us, often as important as our own work to change

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Confidence

• An important predictor of successful behavior change is what behavioral psychologists call self-efficacy.

• Self efficacy is defined as the confidence to sustain a behavior in the face of one’s obstacles.

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Confidence cont’d

• Before proceeding on the path of change, it is vital to have a moderate to high level of confidence in one’s ability to be successful.

• If the confidence score is less than 7 out of 10, then one needs to do more work to increase the level to at least 7 or 8.

• Achieving small behavioral change → rise in confidence →↑ overall confidence in the possibility of more extensive change.

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Positivity: The Mechanism of Action for Resilience

Happiness Unpacked: Positive Emotions Increase Life Satisfaction by Building Resilience ~ Fredrickson, 2009

• Sparkle of good feelings awakens motivation to change.• Positivity starts a psychological chain reaction that

allows you to step up to the next level of existence

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Resilience Tipping Point

• The resilience tipping point is a 3:1 ratio.• Above a 3:1 ratio people have the resources to change

and grow, and bounce back from adversity – they flourish and are on an upward spiral

• Below tipping point 3:1 ratio people languish and are on a downward spiral.

Check your ratio at www.positivityratio.com

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ConfidenceIf you think you can do a thing, or think you can’t do a thing, you’re right. ~Henry Ford

Nothing is particularly hard if you divide it into small jobs. ~Henry Ford

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Confidence: Coaching Inquiry

• What would increase your confidence in making lasting change?

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Commitment• We increase the probability of success when we make

an oral or written commitment to another person. – (eg: family member, friend, colleague, physician, or

coach).• We have a high level of integrity and want to honor our

commitments.

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Commitment

Concerning all acts of initiative and creation, there is one elementary truth–that the moment one definitely commits oneself, then providence moves too.. ~Goethe

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Preparation: Summary

• I have a plan!• I have put plenty of support in place• I have the confidence and resilience I need• I commit to…

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Up We Go: Action Level

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Behavioral Steps• Choosing and refining realistic and specific behavioral

goals is the all-important “doing” part of behavior change.

• Be a scientist – explore and experiment with a variety of approaches to find the ones that fit your DNA

• Commit to consistent practice of a new behavior for at least 3 months

• Maintain it for another 3 months • Reach high confidence by a new habit

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Behavioral Steps cont’d

• The goal should be specific and measurable – replace “exercising more” with – “I will walk four days a week for 30 minutes at a moderate intensity” or “I will shift my response to stressful moments by journaling and choosing to adapt and adjust”

• Building up to the 3 month behavioral goal should progress slowly each week in small steps. – Start walking four days for 10 minutes, or walking two

days for 20 minutes.

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Behavioral Steps: Coaching Inquiry

• What small step can you take next week?

• What experiment can you test this week?

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Behavioral Steps

True life is lived when tiny changes occur. ~ Leo Tolstoy

To climb steep hills requires a slow pace at first.~Shakespeare

Change will lead to insight more often than insight leads to change. ~Milton Erickson

It is in your moments of decision that your destiny is shaped. ~Anthony Robbins

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Rewards

• To reinforce our motivation and confidence, it is important to experience early rewards for our efforts to change.

• We generally start to feel better, stronger, lighter, or more energetic when we start to exercise more, eat better, relax more, or have more fun.

• We need to be mindful and observe, enjoy, and celebrate the rewards.

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Rewards

The human mind once stretched by a new idea, never regains its original dimensions.~William James

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Problem-solving

• While we addressed major challenges as part of the vision, big and small ones emerge

• Challenges and setbacks = opportunities to learn and grow.

• Problem-solving = Opportunity-seeking• Creative brainstorming process, leading to new insights,

action, perhaps tweaking behavioral goals and plan, or modifying strategies to handle obstacles.

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Problem-solving

Growth is not steady, forward, upward progression. It is instead a switchback trail; three steps forward, two back, one around the bushes, and a few simply standing, before another forward leap.~ Dorothy Corkville Briggs

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Problem-solving

Disappointment to a noble soul is what cold water is to burning metal; it strengthens, tempers, intensifies, but never destroys it.~ Eliza Tabor

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Problem-solving

The art of living lies less in eliminating our troubles than in growing with them. ~ Bernard M. Baruch

Problems are only opportunities in work clothes. ~ Henry J. Kaiser

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Up We Go: Results Level

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Lasting Changes

• It feels great when we’ve adopted a new habit and we’re confident that we can sustain the new habit for the foreseeable future.

• Motivation and confidence is high. Mindset and worldview have grown.

• The diligent effort to build up to our behavioral goal and embrace the challenges along the way has a big payoff when we’re successful.

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Relapse Prevention

• Even when we’ve mastered a new behavior, there is still potential to fall off the rails

• Life happens • New challenges emerge as we get older and our lives

get more complex • Developing strategies to prevent relapses

(when we stop doing the new behavior) is the thinking work required when we’ve reached the maintenance stage of change

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Relapse Prevention

• Be a role model or mentor others• Rekindle motivation – values and purpose may have

shifted• New challenges may require new strategies

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Relapse Prevention

You're on the road to success when you realize that failure is only a detour. ~ Unknown

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Up We Go: My Best Self

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Best Self

• Autonomous, competent, motivated, connected self (self-determination)

• One of the big bonuses of lasting change is that our self-image improves – we get closer to the person that we want to be – my best self!

• Take time to notice, embrace, and enjoy your new self-image.

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My Best Self

Change is the handmaiden Nature requires to do her miracles with. ~ Mark Twain

Nothing can bring you peace but yourself. ~ Ralph Waldo Emerson

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My Best Self: Coaching Inquiry

• Who is my best self that is revealed when I take good care of my health and well-being?

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It’s time to…

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Mount Lasting Change

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Lesson Questions

• What are the main stages of lasting behavior change?

• What areas should you work on with patients before setting specific goals?

Lesson Answers

• What are the main stages of lasting behavior change?

Vision, Preparation, Action, Results, Best Self

Lesson Answers

• What areas should you work on with patients before setting specific goals?

Practice Processes for Improving Outcomes

• The provider and team help patients embark on and sustain a journey toward sustainable change by focusing on the change building block suited to their current situation.

Practice Processes for Improving Outcomes: Coaching

• Provider switches from a prescribing role to a coach role to support patients in making behavior changes.

• Each patient is coached in a tailored and effective manner for his/her lifestyle needs.

• Provider and practice team members support patients’ short and long-term goals.

• The provider makes referrals to and collaborates with family members, caregivers, health coaches, worksite programs, and community programs to ensure successful behavior change.


This presentation is based upon coach education and training programs developed and deployed by Wellcoaches Corporation, in partnership with the American College of Sports Medicine.Other Resources1. Book: Coaching Psychology Manual, Lippincott, Williams & Wilkins2. Book: Motivational Interviewing, 3rd Edition3. Book: Changing for Good, Prochaska et al4. Article: Happiness Unpacked: Positive Emotions Increase Life

Satisfaction by Building Resilience ~ Fredrickson, 2009Other Tools (Covered in Coaching 4 & Competency 6 modules)1. Self-Determination Theory2. Social Cognitive Theory3. Positivity4. Character Strengths

Lifestyle Medicine CompetenciesCase Studies

Margaret Moore, MBA

Diane: Case Study• Diane, 30 year old woman, overweight, pre-

pregnancy• Diane has a busy law practice and is eagerly working to

become partner. She has never been a big exerciser and did not participate in team sports growing up.

• Diane has had a serious “sweet tooth” her whole life, especially for chocolate cake and cookies.

• Although she was never excessively heavy growing up, she always considered herself a large framed girl.

• Since her mother’s fight with cancer that ended in a long drawn out death, Diane has been noticing her pants getting tighter and has had to buy new suits for work. Disgusted with herself, she has tried several different diet plans without success.

Diane: Case Study

• How would you show empathy?• What are possible sources of motivation and

confidence?• What would be appropriate SMART goals?

Diane: Express Empathy

• When Diane is talking about her problems listen intently and don’t think about what you are going to say next.

• Show empathy with Diane’s lack of exercise experience growing up and with her difficult time during her mother’s battle with cancer.

• At this point, you could use self-disclosure and share with the patient that you, too, have a sweet tooth so you are familiar with the challenges or that you were not an avid exerciser growing up but now you take walks in the evening. or whatever is true for you.

Diane: Improve Motivation

• Explore and validate Diane’s heartfelt reasons to embark on changing her lifestyle. Ask her what has been motivating her to try different diets.

Diane: Improve Confidence

• Ask her about her confidence level for embarking on lifestyle change and brainstorm possible supports to improve her likelihood of success.

• Discuss her strengths noting that as a lawyer, she must be dedicated, clever, and good at handling detail.

• You can mention that she must have perseverance as she made it through law school, and creativity in order to build strong legal cases, and both of those traits will be useful when adopting healthy lifestyle changes.

Diane: Set Smart Goals• Given that Diane reports feeling, “disgusted with herself”

she might be ready to set a goal for herself. In fact, she might have been thinking about possible steps forward, toward adopting a healthy lifestyle.

• Ask if she is ready to set a goal and what she would want to tackle first.

• Don’t assume that she wants to cut out sweets even though she mentioned that. Make sure that Diane sets a specific, measureable, action oriented, and time sensitive goal.

• If she is not ready to set a goal, then ask her to think about this and contact the office when she settles on one.

• Ask Diane to score confidence and motivation out of 10 and continue to improve both if scores are below 7.

Diane: Develop Accountability• Negotiate and co-create a system of accountability that

works for both of you. • If Diane is having a follow up visit soon, then you can

use this time to check in on the goals. • Depending on your office set up, you could have an

assistant call the patient or email the patient to check in after a week.

• It is important to set up the plan with the patient at the visit and document it. If you have pen and paper in your office, the patient can write down the plan and you can document it in the chart.

Shirley: Case Study• Shirley, 40 year old woman, type 2 diabetes• Shirley is the mother of three children. With her busy

schedule at home, she finds it hard to fit in any regular exercise, despite the fact that she was a college volleyball player and enjoys sports.

• Her children are 10, 8, and 6 and are picky eaters, refusing to eat anything except pizza and mac and cheese. Eating their leftovers has become habit now.

• Shirley is trying to eat less but finds it difficult. Having type 2 diabetes is something that scares Shirley and she wants to lose weight but can’t find the time to commit to healthy eating habits or regular exercise.

Shirley: Case Study



Shirley: Express Empathy

• After listening intently to Shirley, you could nod and use a reflection such as, “It sounds like you are really busy with your three children and finding time to exercise is a real challenge right now.”

Shirley: Improve Motivation

• It appears that Shirley is scared about her diagnosis of diabetes. You could check in with her about this and find out if it is a motivator for her interest in exercise by saying, “I heard you say that your diagnosis of type 2 diabetes worries you.

• What would it take to help mitigate that fear?” Or, “I heard you say that you are trying to fit exercise into your life right now and you are trying to eat less. How would your life be different if you were able to accomplish both of these goals?”

Shirley: Improve Confidence

• You can help build up Shirley’s confidence by pointing out some strengths that you identified while she was telling you her history. For example, you might say, “From what I heard today, you sound like a dedicated mother who is prioritizing her children.

• Being a dedicated mother takes great patience. I also learned that you were a competitive volleyball player, which takes long hours of practice as well as skill.

• These combined strengths of dedication, perseverance, and the ability to train for a competitive sport will all come in handy to help you achieve success in adopting healthy lifestyles.”

Shirley: Set Smart Goals• Ask Shirley if she is currently working towards a specific

goal in terms of eating less, which she mentioned was an overall goal.

• Depending on her answer, you can work to help her create a Specific, Measurable, Action Oriented, Realistic, and Time sensitive goal.

• If Shirley is not interested in creating a SMART goal around eating less, then check in with Shirley and see what is most important to her right now.

• Let her tell you what she would like to tackle first. Then, help her create a SMART goal for that.

• Ask Shirley to score confidence and motivation out of 10 and continue to improve both if scores are below 7.

Shirley: Develop Accountability

• Negotiate and co-create an accountability plan as with the first case.

John: Case Study

• John is a 65 year old colon cancer survivor who is anxious to do everything in his power to remain healthy. He is currently overweight but is trying to change that by exercising 3-5 days a week.

• Since his diagnosis of colon cancer, he has tried to be careful with his diet, avoiding processed red meat and eating more fruits and vegetables. However, he loves bacon, ribs, and ice cream and hates to give up these pleasures.

John: Case Study



• What type of accountability might work?

John: Express Empathy

• Start by acknowledging how hard it is to lose weight.• Then, you can reflect back that you heard John say she

is exercising 3-5 days a week and that she is adding more fruits and vegetables into her diet.

• After that, you can say that you sensed some disappointment and guilt when John spoke about ribs and ice cream yesterday.

• At that point, you can say something like it is sometimes hard to quit a habit, especially if it gives you pleasure.

John: Improve Motivation

• Tapping into John’s motivation to “do everything in her power to remain healthy” after his colon cancer treatment is a good place to start.

• By saying, “It sounds like you are already moving in a positive direction with your desire to remain healthy after your battle with breast cancer. What do you think will keep you focused and on track with this desire in the long run?”

John: Improve Confidence• By spending a moment congratulating John on his

exercise routine that he started, you can help empower John to continue to tackle lifestyle behavior challenges in the future.

• You can ask John how she mustered up the energy and commitment to get that done. Then, you can move to his diet and congratulate him on the changes that he already made and ask him a similar question. How did he make that change happen?

• By having John connect with his successes in the area of exercise and diet, you can set him up for feeling confident to tackle more obstacles, like ribs and ice cream.

John: Set Smart Goals

• Ask John what goals he would like to commit to for the upcoming weeks. Again, do not assume or even suggest that he simply “stop eating ribs and ice cream.” See what he comes up with.

• John brought up the ribs and ice cream and he knows it is a problem. If he wants to tackle this as her first goal, that is fine. If he chooses something else, follow her lead, as he may need more time before she tackles these “guilty pleasures.”

• Make sure to help John create specific, measurable, action oriented, realistic, time sensitive goals.

• Ask John to score confidence and motivation out of 10 and continue to improve both if scores are below 7.

John: Accountability

• Negotiate and co-create an accountability plan as with the first case.

Rachel: Case Study• Rachel is a 73 year old woman with heart disease. She

recently suffered a heart attack. Currently, she is in the obese category by BMI. She also has a disabled grown child to support.

• Although her cardiologist insists that she stop eating junk food, Rachel can’t afford better quality food.

• Since Rachel has been sedentary for over 30 years, she is not only hesitant to start an exercise program now but also scared that her physical activity will bring on another heart attack. Plus she can’t afford exercise clothes and a gym membership.

• Rachel feels that she can’t afford a healthy lifestyle, it is too late to change, and she does not think that losing a little weight will do much for her anyway.

Rachel: Case Study



• What type of accountability might work?

Rachel: Express Empathy• First reflect what you heard, “It sounds like you have

been through a lot with your recent heart attack, your cardiologist insisting that you stop eating some of the foods that you most enjoy, and your fear that exercising will bring on another heart attack.”

• You can also reflect back her powerful statement, “I heard you say that you can’t afford to buy healthy food, you feel it is too late to change, and you feel that losing a little weight will not do much anyway.”

• By repeating Rachel’s words, you are letting her know you were listening and that you care. She is more than likely expecting you to side with her cardiologist and give her another lecture on diet and exercise, and your response will surprise her.

Rachel: Improve Motivation

• Rachel did talk about being afraid of another heart attack, and you can use this as a starting point. “You mentioned that you are afraid of another heart attack. What do you want to do to help reduce your risk of another heart attack?

• Another tactic would be to ask, “How would your life be different if you had more energy from healthy foods, and felt confident and comfortable exercising, instead of fearful?”

Rachel: Improve Confidence

• It sounds like Rachel has been beaten down. You can ask her, “What would it take for you to feel confident about your future health?”

• By emphasizing that Rachel is a survivor, you can help increase her confidence. “Rachel you are a survivor. You survived a heart attack. I bet you have been successful at many things in your life. Tell me about one of them.”

• Ask her whether she is aware that many healthy foods are affordable, e.g. frozen fruits and veggies

Rachel: Smart Goals• See if Rachel is ready to set any goals during this visit. If she is not,

you can ask her to think about a goal she would love to achieve by three months.

• Do not jump in and start setting weight loss goals, exercise goals, and diet goals, even if that is what you are first compelled to do.

• In Rachel’s case, a goal might be to investigate low cost healthy foods, or ways to walk and exercise cheaply, or how to avoid another heart attack. You could not set these goals for her, but if she says she has no idea what goals to strive for, you could ask permission to brainstorm together.

• These might be some ideas that you toss out to her and see if any of them catch her interest. Remember it is her agenda. You must honor her autonomy.

Rachel: Accountability

• Negotiate and co-create an accountability plan as with the other cases.

Lesson Q&A

• What are the main coaching skills to use in physician visits?

1. Express empathy

2. Improve motivation

3. Improve confidence

4. Set SMART goals

5. Develop accountability plan

Practice Processes to Improve Outcomes: Coaching

• Help patients initiate and sustain lasting change in mindset and behavior by:– Showing empathy– Eliciting self-motivation– Building confidence– Setting SMART goals– Planning for accountability


This presentation is based upon coach education and training programs developed and deployed by Wellcoaches Corporation, in partnership with the American College of Sports Medicine.

Other ResourcesLifestyle Medicine textbook, 2nd Edition, J. Rippe et al. Chapter 27: Health and wellness coaching: Skills for lasting change

Documents

Lifestyle Medicine Competencies