Case study: Health Based Coaching

This essay will provide a general overview of Motivational Interviewing (MI) and Cognitive Behavioural Therapy (CBT), two Psychological approaches that can be applied within the context of health based coaching. The benefits of these approaches in helping to achieve health-related objectives as well as some research and underpinning models and theories will be discussed.

This essay will also describe in more detail how I would like to apply Motivational Interviewing within the context of my Health Coaching Practice as well as the way I would evaluate its effectiveness.

Motivational Interviewing (MI)

MI is defined by Rollnic and Miller (1995) as

‘a directive, client-centred counselling style for eliciting behaviour change by helping clients to explore and resolve ambivalence.’

In other words, MI is a person centred approach that has a clear agenda of motivating clients towards committing themselves to change and more positive health behaviours. Although it is considered as a directive style, the aim is to lead the client from feeling stuck and ambivalent about change towards identifying discrepancy between personal life values and the actual behaviour taking place. Through this process the MI coach empowers the client to move towards making autonomous decisions that are more in line with the person’s values and which may lead to better health outcomes. In this way, MI creates a less confrontational environment than the normal ‘telling’ patient advice.

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The most important factor in MI is not the use of skilful technique but rather, the Spirit of MI which must flow through the process. The spirit of MI is manifested through a respectful and empathic collaborative relationship which is built around autonomy of the client and the evocation of intrinsic motivation towards change in behaviour. The principles and techniques of MI are based on expressing empathy, resisting the righting reflex, rolling with resistance, understanding the motivation of clients, developing discrepancy, and supporting self-efficacy and empowerment (Rosengren, 2009; Rollnick, Miller & Butler, 2008).

MI has been adopted as a counselling style to elicit intrinsic motivation towards positive change through resolution of ambivalence (Lundahl & Burke,2009, Markland et al., 2005). It was originally described by Miller (1983) as evolving from the management of problem drinking but since then it has been expanded to a wider range of health contexts including smoking cessation (Rollnick, Butler, & Stott, 1997; Butler et al., 1999), drug addiction (Saunders,Wilkinson, & Allsop, 1991; van Bilsen, 1991), prevention of HIV (Baker, Kochan, Dixon, Heather, & Wodak, 1994) and other health behaviours (Markland et al., 2005). A meta-anlysis by Burke, Arkowitz, and Menchola (2003) showed that outcomes of MI were equivalent to other active treatments and yielded moderate effects when compared with no treatment and/or placebo for problems involving alcohol, drugs, and diet and exercise. Results did not support the efficacy of MI for smoking or HIV-risk behaviors.

Although MI has been criticized as lacking a theoretical base (Draycott & Dabbs, 1998) it is building up its conceptual roots in several underpinning Theories related to motivation and change including the:

Theory of Self-Determination (Deci & Ryan, 2000). Self-determination theory (SDT) states that people are intrinsically driven towards growth, self-integration and resolution of psychological inconsistency (e.g. ambivalent situations). When behavioural change may be required, the autonomous regulation of behaviour is considered to lead to more sustainable positive results than behaviour which is controlled by others. SDT describes three psychological needs in such change situations, namely the need for competence to achieve change, a sense of autonomy in taking decisions and the need to relate to others who are ready to invest in their well being. The parallels between SDT and MI are thus quite striking. A key MI assumption is that it is the client’s responsibility, not the counsellor’s, to decide on whether or not to change and what actions to take (autonomy). The MI process assists in gaining internalization and integrated regulation through alignment with internal values to remove psychological inconsistencies. Through a person-centred approach and empathy the need to relate to others is honoured (relatedness). Also as the MI process progresses the Coach will help the client to develop achievable, self-selected goals that increase self-efficacy (competence). Thus, MI is closely aligned to SDT’s concept of personal growth, integration and internal cohesion which can help people to self-regulate healthy behaviour and sustain it (Markland et al., 2005, Ryan et al., 2008).

Social Cognitive theory (Bandura, 2004). The core determinants of the Social Cognitive theory include knowledge of health related risks and beneficial behaviour, perceived self-efficacy related to the ability to control such behaviour, outcome expectations that include both benefits and costs of changing behaviour, the goals that are decided upon and the perceived facilitators or impediments (including social) that may assist or thwart the person’s willingness to change. As in the SD Theory, Social Cognitive theory relates well with MI since provision of knowledge, promotion of self-efficacy, exploration of outcomes, planning goals and enhancing facilitators and mitigating impediments all form part of the process of MI.

Transtheoretical Model of Behavioral Change . The 5 stage progress from precontemplation, to contemplation to change, preparation for action, action, maintenance, to possible relapse (Prochaska, DiClemente and Norcoss, 1992) are also evident within the process of MI.

Other related Theories include Cognitive dissonance, and self-efficacy (Miller, 1983), Theory of Planned Behaviour (Ajzen, 2002), Bem’s Self-Perception Theory, and Janis and Mann’s Decisional Balance Theory (Welch, Rose & Ernst, 2006).

Following the description of Cognitive Behavioral therapy, an explanation of the application of MI in the practical context will be provided.

Cognitive Behavioral Therapy (CBT)

CBT is a short-term psychological therapy with the underlying concept that our thoughts influence the way we feel and behave and that by changing extreme unhelpful thoughts and behaviour we can create improvement in how we feel. CBT includes various schools of psychological approaches including, Rational Emotive Therapy, Cognitive Therapy and Multimodal Therapy (David & Szentagotai, 2006). These have been proven through research to be effective treatment for a variety of psychological problems, including depression, anxiety, panic, phobias, eating disorders and OCD (Hazlett-Stevens & Craske, 2002; Craig & Boardman, 1997). Meta-analytic studies have also confirmed their effectiveness (Butler & Beck, 2000; Engels, Gemefsky & Diekstra, 1993).

Though the basic concept of CBT can be traced back to the time of the Stoics, CBT’s origin can be associated with the phenomenological theories of knowledge about how people perceive their own reality of life (Husserl, 1960). Although CBT encourages clients to test their cognitions against ‘reality’ there is still a significant emphasis on the subjective experience of the client. The most important influences and Models supporting CBT include Albert Ellis’s rational emotive therapy and Aaron Beck’s Cognitive Model of Depression which states that early experiences in life can lead to the creation of dysfunctional beliefs, schemas, and a negative self-concept, which in turn will lead to depression. He referred to this negative bias in the way one looks at life as the negative triad–that is, a negative view of self, of experiences and of the future (Leahy, 1996). Cognitive distortions such as all-or-nothing thinking, catastrophizing, overgeneralization and mind reading have also been identified (Freeman, 1987).

CBT, like Coaching, focuses on present difficulties, rather than the past or unconscious motivations. Although it is directive in nature with a focus on helping clients to learn new ways of thinking and behaviour, it is also empowering as it helps clients improve on specific psychological and practical skills to tackle problems by activating their own intrinsic resources. Key factors in the provision of effective CBT include a therapeutic and trusting relationship using ‘guided discovery’ or Socratic dialogue to help the client identify automatic thoughts as they spring to mind. These are probed for associated meanings or beliefs, following which cognitive restructuring and alternative viewpoints are encouraged (Grazebrook & Garland, 2005).

Beck and Emery (1985) provide specific questions to aid in such cognitive restructuring. These include questions around the evidence which support current beliefs of the client, other ways the client can look at the same situation whilst reaching new and more effective conclusions and questions related to what can actually happen if the client’s conclusions are correct. Following such guided discovery the Coach can then suggest behavioural experiments to assess the accuracy of such conclusions and to try out new ways of thinking and behaving (Grazebrook & Garland, 2005). In this way, specific thinking patterns and behaviour are targeted to overpower any past information processing and maladaptive learning (Hazlett-Stevens & Craske, 2002).

A well known CBT model used is the ABCDE model which involves identifying the activating event, looking at beliefs and consequences, disputing irrational thoughts and taking action to change thinking and experimenting with new ways of actions and behaviours (David & Szentagotai, 2006). Other factors included in the acronym CHANGE VIEW include doing homework, identifying needs, creating goals and taking action, viewing events from another angle, enhancing self-efficacy, testing out old and new beliefs through experience and writing down to remember progress. Computer-assisted therapy has lately also become a method of providing CBT on line especially for obesity and weight reduction (Hazlett-Stevens & Craske, 2002).

Some criticism has been levelled towards CBT in that people may feel that the therapist can be ‘leading’ in their questioning and somewhat directive. Another criticism of the CBT approach is that it ignores the role of life events and the social environment (Gilbert 1992 Weishaar, 1993). Also David & Szentagotai, (2006) state that with ten different schools of CBT the theory behind it may look like a ‘Babel Tower’ even though CBT is proven to be effective.

The relevance of CBT in Health Coaching is that it can be integrated to assist a person in self-monitoring for irrational thinking and limiting beliefs related to change and in developing new practical skills such as assertiveness, problem solving, journaling, role-playing, relaxation techniques and homework to practice new behaviour.

Applying MI in Coaching

Currently, MI is the only health-coaching technique that has been described in detail and consistently demonstrated effective positive behavioural outcomes (Butterworth, Linden & Clay, 2007). Because of this I intend to apply the skills of MI as my primary approach in Health coaching. However, I also intend to use an eclectic approach that ‘borrows’ approaches from other Theories or Models related to Health Coaching.

An interesting Health Coaching Model I met with during my research on the subject is the HCA Model of Health Change by Gale (2010).

This Model is not as yet rigorously researched since I could not find evidence-based literature on it, however it is a structured 10 step approach that incorporates aspects from well known health behaviour change models such as the Transtheoretical Model (Prochaska & DiClemente, 1984), Self-efficacy (Bandura, 1977 ) and The Theory of Planned Behaviour (Ajzen, 1991) amongst others. This model uses an MI approach until the client comes to a point of taking a decision to change and then moves into Solution-focused coaching once the decision to make a change is taken.

Following the review of literature related to Health Based Coaching I have created my own 6 Stages (Appendix 1) as a reference to Guide me through the process. Certainly the course of the session will need to be flexible so as to provide individualized coaching, however by having these steps I can provide a more structured and research-based approach.

Stage 1 – Building a rapport with the client (Self-Determination Theory, MI approaches)

During this stage I would explain the procedure to the client, gain consent and go through the issue of confidentiality. I would also inform the client that he or she will be in full control as regards any decisions taken during the session. I would work on creating an environment that is empathic and that supports autonomy and relatedness.

Stage 2 – Identify and explore issues (MI approach)

At this stage I would move into setting an Agenda. I would use a ‘Things to talk about Chart’ to identify issues for discussion. After agreeing on 3-4 issues, I would continue the process by using open-ended questions, affirmations, reflections, and summaries (OARS) to continue the process of helping the client to open up and feel safe to explore issues. As the client starts to discuss the situation, I could ask for a description of a typical day so that any patterns or associations related to the issue can be brought to light. During the process I would focus on using reflections more frequently than asking questions (an average ratio of 2:1) and also be aware both for opportunities to affirm any positive past or present actions as well as for any indication of change talk.

Step 3- Identify ambivalence and provide feedback (MI approach, Transtheorethical Stages of Change Model)

As the process continues I will assess at what stage the client is within the Stages of Change Model. Is the person still in the pre-contemplative stage or has there been a movement towards contemplating change? Is the person verbalizing ambivalence about change?

If ambivalence is present I could use the ‘Good things and Less Good things’ chart to assist the client to clarify the issues surrounding ambivalence. Although this exercise can be a two-edged sword since the client will be verbalizing the hindrances to change, I can put more emphasis and reflections on the positive aspects of the client’s feedback. At this stage it will be important for me to roll with any resistance and avoid confrontation. If the client becomes resistant at any stage this will be a reflection on my style and I would need to be more empathic.

During this stage I could explore the knowledge of the client about specific issues using E.P.E (Elicit-Provide-Elicit) to identify knowledge of client related to subject. After gaining permission I could then provide further information in a non-judgemental fashion and voice a concern about the client’s present behaviour if required. I would then elicit the client’s reaction to the information and concern

Stage 4- Develop discrepancy (MI approach)

The ‘Good things and Less Good things’ exercise should have provided an indication about the client’s core values and this can be further explored. I can now reflect back these values and compare them with any present ‘negative’ behaviour in a non-judgemental and non-confrontational manner. Through reflections I can raise the need for change in a subtle way and continue to use OARS and help the client develop discrepancy between ideal core values and present behaviour. The use of evocative questions, elaboration, using extremes, and looking back in the past and forward to potential futures can help to elicit change talk. By ‘picking up the flowers’ and reflecting back any potential change talk I can guide the client towards verbalising more change talk. If this is not present and the person is still resistant. If, on the other hand the client is verbalizing clear change talk I can use at Transitional Summary and end with a Key Question to explore what specific actions the client would like to take in relation to change.

Stage 5- Identify change goals (MI, Solution-focused coaching and CBT approaches- Broaden-and-Build Theory, Theory of Self-Determination)

If the client verbalises the desire to change, specific goals can be explored. At this stage, I can use other approaches if required. If the client demonstrates limiting beliefs or negative self-talk, CBT approaches can be used to help the client monitor these thoughts, test them and come up with new more positive beliefs. Solution-focused coaching can also be used to visualize a better future and to create specific and SMART goals that are ‘chunked’ into small achievable steps. The use of a ‘Menu Options’ sheet with can be used to provide suggestions for clients. These can include ideas on how to build positive emotions in line with the Broaden-and-build Theory.

Stage 6- Commit to the change (Social Cognitive and Self-Efficacy Theories, MI, Solution-focused Coaching, CBT)

During the final stage the level of commitment for the stated goals will be assessed using scaling questions for commitment and perception of self-efficacy. The DARN-C approach will also be used to identify the desire, need, ability, need and commitment to change. Outcome expectations and exploration of perceived facilitators and impediments can be carried out to further enhance the plan and reduce potential problems. I may use MI, CBT or Solution-focused coaching approaches as required to further help the client to mobilize resources and potential support. I will also suggest that the client plan a reward if the outcome is successful.

Evaluation of my Coaching

As in any therapeutic approach, it is very important to evaluate the outcomes of the sessions as well as one’s own personal performance as a Coach. This is especially so because research demonstrates that most counsellors who say they are doing MI are not doing it correctly (Martino et al., 2006).

The way I intend to evaluate my practice is through the use of an adapted form of the ‘MI Clinician Self-Assessment Report available in the ‘Interviewing Assessment: Supervisory Tools for Enhancing Proficiency’ by Martino et al. (2006). This is a really good on-line document for MI practitioners and it provides a very good overall tool to assess one’s practice. Since I would also be including CBT and Solution-focused Coaching at times I have also included some statements related to these skills in my adapted Assessment Form found in Appendix 2. Following my Self- Assessment I will use the Health Coaching Skills Development Plan Form (Appendix 3) to identify specific areas I would like to develop further to hone my Coaching skills.

Conclusion

We have reviewed two psychological approaches that can be used in Health Coaching, namely, MI and CBT. The difference between the two approaches has been looked into. We have seen that MI focuses on motivating clients towards moving from ambivalence towards taking decisions leading to behavioural change without going into the actual skills development. On the other hand CBT focuses mostly on psycho-education and skills development related to thinking patterns, feelings and behaviours so as to avoid thinking traps. We have also looked into some supporting Health related Theories that underpin the Health Coaching Model. In discussing the application of Health Coaching I have chosen MI as the main approach with CBT and Solution-focused coaching as supporting approaches and created a 6 stages to structure my practice. Finally I have also identified a way to evaluate my practice so as to continue to develop my coaching skills.

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APPENDIX 1

Stage 1 – Build a rapport with the client

Explain and discuss process and confidentiality

Sign consent form

Reassure regarding autonomous decision making and the need for a collaborative relationship.

Relate to the client and show empathy (Theory of Self-Determination)

Stage 2 – Setting the Agenda and initial exploration

Agenda setting: Use the ‘Things to talk about Chart’ to identify issues

Agree on 3-4 issues to discuss

Use OARS to start MI process

Invite client to describe a typical day

Summarize as required

Stage 3- Assess readiness for change and exploring ambivalence

Identify at where the client is within the Stages of Change Model

Use the ‘Good things and Less Good things’ chart to clarify ambivalence

Roll with resistance -reflecting, reframing, agreeing with a twist, emphasizing personal choice, double sided reflections,

Use E.P.E (Elicit-Provide-Elicit)

identify knowledge of client related to subject

request permission to provide information

provide information in a non-judgemental fashion

voice a concern if required

elicit the client’s reaction to the information and concern

Continue using OARS

Stage 4- Develop discrepancy and Change talk

Identify and reflect back the client’s Values and the ‘good things’ about stopping negative behaviour – ‘pick up the flowers’

evocative questions, elaboration, using extremes, and looking back in the past and forward to potential futures

Compare core values with actual present behavior

Raise awareness of the need for change

Use DARN-C: to identify Desire, Ability, Reasons and Need for change

Continue to use OARS and note any indication of change talk and if required CBT approaches for any limiting beliefs using the E.P.E (Elicit-Provide-Elicit) approach

If change talk present use a Transitional Summary

Stage 5- Identify change goals

Work towards having the client clarify specific goals to achieve

Use Menu Options sheet to help client come up with alternatives

Identify activities that can help the patient to feel more positive, empowered, grateful for life and mindful (Positive Psychology).

Create SMART goals using solution focused coaching approaches.

Chunk down activities into specific action steps

Stage 6- Commit to the change (Social Cognitive theory, MI & Solution focused coaching)

Explore past successes

Use the C of DARN-C to assess readiness to change and level of Commitment using scaling questions for commitment and level of self-confidence

Identify outcome expectations and work on enhancing the perceived facilitators and reducing the impediments (Social Cognitive theory).

Identify who will support client to achieve goal and decide on a reward.

Adapted from Miller and Rollnick (1991)