Coaching For Behavior Change In Physiatry
Authors:Elizabeth Pegg Frates, MDMargaret A. Moore, MBACeleste Nicole Lopez, MDGraham T. McMahon, MD, MMScWellnessAffiliations:From the Spaulding RehabilitationHospital, Harvard Medical School(EPF); Institute of Coaching, McLeanHospital (MAM); Stanford UniversitySchool of Medicine (CNL); andBrigham Women’s Hospital, HarvardMedical School (GTM).Correspondence:All correspondence and requests forreprints should be addressed to:Elizabeth Pegg Frates, MD, SpauldingRehabilitation Hospital, 125 NashuaStreet, Boston, MA 02114.COMMENTARYCoaching for Behavior Changein PhysiatryABSTRACTFrates EP, Moore MA, Lopez CN, McMahon GT: Coaching for behavior changein physiatry. Am J Phys Med Rehabil 2011;90:1074Y1082.Disclosures:Financial disclosure statements havebeen obtained, and no conflicts ofinterest have been reported by theauthors or by any individuals in controlof the content of this article.Margaret A. Moore is the CEO andFounder of Wellcoaches Corporation,a coach training school for healthprofessionals, affiliated with theAmerican College of Sports Medicine.0894-9115/11/9012-1074/0American Journal of PhysicalMedicine & RehabilitationCopyright * 2011 by LippincottWilliams & WilkinsDOI: 10.1097/PHM.0b013e31822dea9aBehavior modification is vital to the prevention or amelioration of lifestyle-relateddisease. Health and wellness coaching is emerging as a powerful intervention tohelp patients initiate and maintain sustainable change that can be critical to physiatry practice. The coach approach delivers a patient-centered collaborative partnership to create an engaging and realistic individualized plan. The coachingprocess builds the psychologic skills needed to support lasting change, includingmindfulness, self-awareness, self-motivation, resilience, optimism, and self-efficacy.Preliminary studies indicate that health and wellness coaching is a useful andpotentially important adjunct to usual care for managing hyperlipidemia, diabetes,cancer pain, cancer survival, asthma, weight loss, and increasing physical activity.Physiatrists can benefit from the insights of coaching to promote effective collaboration, negotiation, and motivation to encourage patients to take responsibilityfor their recovery and their future wellness by adopting healthy lifestyles.Key Words: Health Coaching, Health Behavior, Behavior Change, Health Outcomes,Physiatry, Motivational InterviewingUp to half of all premature deaths are caused by unhealthy lifestyle choicesrelated to tobacco, sedentary behavior, unmanaged stress, and poor diets. As theprevalence of obesity continues to rise, effective strategies to address the physicalactivity and diet of patients have become even more crucial today than it was inthe past. Health and wellness coaching uses a collaborative patient-focused approach to enable patients to take responsibility for their health and well-being, toincrease self-awareness, to harness heartfelt motivation connected to life valuesand purpose, to commit to realistic goals, and to adopt a resilient and confidentmindset as they experiment with and eventually establish healthy behaviors.Effective coaching deals with both large and small challenges and builds onopportunities, including past successes and failures. The process supports positive change in a number of ways: by helping patients gain the lifestyle and psychologic knowledge that they are seeking, by helping them acquire the copingand behavior change skills that they need, and by applying their strengths, talents,and experience to their health goals.1074Am. J. Phys. Med. Rehabil. & Vol. 90, No. 12, December 2011Copyright 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
PSYCHOLOGY OF COACHINGResearch examining human behavior changehas shown that the external expert source of motivation, which is typically used by clinicians, generates either compliance or defiance and is notreliable. External sources of motivation alone donot generate the internal motivation that mostcorrelate with lasting engagement in health behaviors, where patients uncover their own reasonswhy a behavior is in their best interest and thenplace a high value on the outcome. Human beingsare wired to want autonomy and resist being toldwhat to do, even when the advice is in their bestinterest.The roots of professional coaching in healthcare are firmly planted in evidence-based psychologic domains and theories on how to generateeffective and durable behavior change, not onlyself-determination theory1 but also many othersincluding the transtheoretical model of change,2motivational interviewing,3,4 appreciative inquiry,5goal-setting theory,6 social cognitive theory,7 adultdevelopment,8 cognitive behavioral therapy,9 andpositive psychology.10,11 The assimilation andtranslation of these theories into coaching skills,knowledge, and processes have given health andwellness coaches a road map for the facilitation ofthe patient’s process of change, including change inthinking (beliefs and attitudes), emotions (moremindfulness and resilience), and behaving (newhealthy habits).Physicians are trained in an Bexpert approach,[which is problem focused and relies on the clinician’s skills and knowledge to determine the correct diagnosis and treatment for each patient. Thisapproach is most effective when handling acuteproblems and emergency situations. Patients expectthis approach when they enter the doctor’s office fora sick visit. However, this same expert approach isoften used to advise patients about making behaviorchanges such as initiating an exercise routine orlosing weight and cutting down on salt intake.Sometimes, patients adhere to expert advice, butmore often, they do not. The role of the physician ascoach is different from his role as an expert in manyways (Table 1).Clinical EvidenceSeveral clinical trials with a variety of populations suggest that the coach approach appears to beeffective in generating short-term, and perhapsmore durable, behavior change (Table 2). A widevariety of patients have responded favorably to collaborative coaching efforts, ranging from childrenwith asthma to adults with cancer pain. The benefitsof coaching interventions have included increasedpersonal behaviors (such as exercise), improvedmeasures of health (such as reduced cholesterol, orHbA1c) and reduced health utilization (such ashospitalization). Effective health and wellnesscoaching interventions used live sessions, on thetelephone or in person. Common aspects of successful coaching interventions included a consistent one-on-one relationship, goal setting, andaccountability through reporting to the coach on aregular basis.Although the effectiveness of health and wellness coaching has been demonstrated in broadpopulations with diverse health concerns, there arelimitations as to the current evidence for healthcoaching. Most studies have small sample sizes. Avariety of coaching techniques and training hasbeen used in studies. In addition, there is variabilityof the number, frequency, and duration of coachingsessions used. Long-term follow-up beyond 2 yrshas yet to be completed.Many areas of uncertainty remain. A consistentdefinition of health and wellness coaching, alongwith standards for competency training and credentialing, need to be established. Which techniques can be most useful for particular mindsets,readiness to change, and disease states remains anarea of active exploration. How the expert educatorTABLE 1 The differences between the expert approach and the coach approachExpertCoachTreats patientsEducatesRelies on skills and knowledge of expertStrives to have all the answersFocuses on the problemAdviseswww.ajpmr.comHelps patients help themselvesBuilds motivation, confidence, and engagementRelies on patient self-awareness and insightsStrives to help patients find their own answers.Focuses on what is working wellCollaboratesCoaching for Behavior Change in PhysiatryCopyright 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.1075
TABLE 2 Randomized controlled trials of health and wellness coachingAuthorDesignSubjects56 patients withRCT comparingtype 2 diabetesintegrative healthcoaching with usualcare (control)Whittemore Pilot RCT; nurse53 women with13et al.type 2 diabetescoach vs. usual care;intervention groupreceived a nursecoach interventionFourteen 30-mincoaching sessionsby telephoneover 4 mosSix coaching sessionswere delivered over6 mos.Vale et al.14 RCT; COACH vs.usual care792 patientswith CVDFive telephonecoaching sessionswere deliveredfor 6 mos.Vale et al.15 RCT; coach model vs.usual care245 CHD patients Six telephonecoaching sessionswere deliveredfor 6 mos.Woleveret al.12Edelmanet al.16Debaret al.17Fisheret al.18Oliveret al.191076InterventionFrates et al.ResultsSignificant reduction inA1c among participantswith baseline values Q7%(P 0.03)Intervention subjects hadbetter dietself-management(P 0.02), lessdiabetes-related distress(P G 0.01), betterintegration (P G 0.03),greater satisfaction withcare (P G 0.01) , andtrends toward betterexercise self-management(P 0.13) and lowerBMIs (P 0.15)Intervention subjectsdemonstrated greaterdecrease in totalcholesterol (P G 0.0001),more weight loss(P G 0.0001), greaterreduction in fat intake(P 0.04), and morewalking activity(P G 0.0001)Intervention subjects hadsignificantly lower fastingtotal cholesterol(P G 0.0001) andLDL-C levels (P G 0.0004).Intervention subjects hadsignificantly greaterdecrease in CHD risk(P 0.05), greaterincrease in number ofdays of exercise per week(P 0.002) and greaterweight loss (P 0.54)Intervention subjects hadhigher BMD in the spine(P 0.007) and trochanter(P 0.03) regions andgreater consumption ofcalcium (P G 0.001) andfruits and vegetables(P 0.01) for 2 yrs154 patients with 28 two-hourin-person groupone or more CVtraining sessionsrisk factorwith biweekly20- to 30-minindividual telephonesessions for10 mosRCT; group meetings228 teenage girls Annual visits, fitnessand coaching vs.center membership,usual carebiweekly teammeetings, quarterlytelephone sessions,and team meetingswith parents, all ofwhich are supportedby a study website.Intervention subjects hadTelephone andRCT; child and parent 191 childrensignificantly lowerin-person visit withreceived coaching vs.ages 2Y8 yrsrehospitalization ratesparent then biweeklyusual carewith diagnosis(P 0.002).telephone calls forof asthma3 mos, after whichcalls were monthlyfor the duration ofthe 2-yr intervention.87 cancer patients 20-min visit before visit Intervention groupRCT; individualizedwith doctor.experienced lower painwith moderateeducation andseverity (P 0.014).paincoaching vs. usualcare group withadditional educationRCT; personalizedhealth plan and ahealth coach with amedical provider vs.usual care plushealth reportAm. J. Phys. Med. Rehabil. & Vol. 90, No. 12, December 2011Copyright 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
TABLE 2 ContinuedAuthorDesignHolland RCT; nurse coach vs.et al.20usual careSubjectsInterventionResults504 subjects witha chronic healthconditionGroup classes on healthtopics and three 1-hrexercise trainingsessions with 11contact hours withthe nurse healthcoach by telephoneand email for 12 mos.Intervention subjectsdemonstrated increasedminutes of weekly aerobicactivity (P 0.001) andincreased minutes ofweekly stretching(P 0.008)COACH, Coaching Patients on Achieving Cardiovascular Health; RCT, randomized controlled trials; BMI, body mass index;CVD, cardiovascular disease; LDL-C, low-density lipoprotein cholesterol; CV, cardiovascular; BMD, bone mineral density.approach can be most effectively combined with thecoach approach needs to be more fully elucidated.Initiating and Maintaining theCoaching RelationshipMany patients need help in making behaviorchanges that are long lasting. For some patients, ahealth setback serves as a sufficient motivator toenable commitment, sustained action, and successin changing their unhealthy habits. For others, evena dramatic serious outcome (such as a myocardialinfarction or a preventable lower limb amputation)may be insufficient to generate behavior changes(such as smoking cessation). In those cases, clinicians can use coaching techniques to make counseling time more effective and more efficient.In a study examining different approaches forpromoting physical activity in a primary care setting, it was demonstrated that 30 mins spent in abrief negotiation conversation with the subject wassignificantly more effective than a no-interventioncontrol in increasing the patient’s physical activitylevels. It was estimated that the subjects in the briefnegotiation group walked approximately 37 minsmore during the week compared with the controlgroup. Brief negotiation involved using motivational techniques such as giving feedback about thecurrent level of activity compared with guidelines,assessing motivation and confidence for increasing physical activity, weighing pros and cons ofincreasing activity levels, information exchange,exploring concerns about increasing activity, andhelping in decision making. In contrast, it wasdemonstrated that 30 mins spent directly advisingthe subject about increasing physical activity levelsyielded no significant difference compared withthe no-intervention control group. Direct advicewas described as telling the subject about benefitsof physical activity and the dangers of sedentarybehavior, instructing the subject to work towardwww.ajpmr.com30 mins of brisk walking (or a similar activity)during at least 5 days of the week. If a caregiver isgoing to spend the time (20Y30 mins) counselingthe patient about increasing physical activity, themost efficient and effective use of time will be tohold brief negotiations and to collaborate with thepatient rather than persuading and coercing thepatient to follow set guidelines.21The coach approach centers on a collaborative partnership between provid
Coaching for Behavior Change in Physiatry ABSTRACT Frates EP, Moore MA, Lopez CN, McMahon GT: Coaching for behavior change in physiatry. Am J Phys Med Rehabil 2011;90:1074Y1082. Behavior modification is vital to the prevention or amelioration of lifestyle-related disease. Health and wellness coaching is emerging as a powerful intervention to
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Coaching program flow This is a generic coaching program flow that can be tailored to organisational and individual needs. Typically coaching programs are six months (nine hours of coaching) or 12 months (15 hours of coaching). Coaching Approach Overview and outcomes In my approach, responsibilities are shared. The coachee drives responsibility
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