Health coaching expert Professor Stephen Palmer focuses on the cognitive behavioural approach to health coaching
The cognitive behavioural approach12 to health coaching is based on helping a client to examine Health Inhibiting Thinking and strengthen Health Enhancing Thinking so they can achieve their desired Health Enhancing Behaviours and goals. It uses an overall structure to coaching meetings to maintain a business-like approach. A typical structure is:
1 Check in with the client to see how they are.
2 Collaboratively develop an agenda for current meeting (eg, develop health-related goals and action plan).
3 Feedback and link to previous meeting and review progress.
4 Discuss the agenda for the session.
5 Collaboratively develop an assignment related to the health coaching goals (eg, join a gym).
6 Seek feedback about the session at end of meeting.
Structures should be applied in a flexible manner. For example, if the client is in the pre-contemplation stage, more time is spent addressing ambivalence to change and less on assignments.
Scaling
Once health-related goals have been developed, the client should note down on two 0 to 10 scales how important achieving the health goal is to them, and how confident they are in achieving it. If the scores are low, the client may have low self-efficacy. It could be an indicator that more Motivational Interviewing is still necessary.
HITs and HIBs
Once the health coaching has started, the client sometimes has a psychological block. Cognitive behavioural techniques can be used to raise awareness of the Health Inhibiting Thinking (HIT) that may be blocking them. One of the easiest methods is to ask the client if they recognise any HITs from the ‘HIT List’ (see box, left).
Clients can also consider the impact HITs have on them having Health Inhibiting Behaviours (HIBs). For example, “I can’t stand hard work” (HIT) could lead to procrastination and the avoidance of an exercise programme (HIB).
To counter the HITs, it is important to develop Health Enhancing Thinking (HET). Once a key HIT has been elicited, the health coach can use Socratic questioning to assist the client to reflect on it and subsequently modify it if they so wish. Questions focus on whether or not a belief is logical, realistic (and empirically correct) or pragmatic (ie, helpful). An illustrative case is shown (right).
In The Health Coaching Toolkit part 4, we focus on additional cognitive thinking skills to help clients strengthen their HETs.
The HIT List
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All-or-nothing thinking? (If a task is worth doing, it’s worth doing well. As I can’t achieve all my health goals, what’s the point of continuing this health programme)
Mind reading (My health coach doesn’t think I can achieve my goal)
Assuming my view is the only possible one (Achieving my goals is just impossible)
Disqualifying the positive (Achieving that goal was nothing. Anybody could have started walking for 15 minutes each day)
Focusing on the negative (Although I’ve changed my lifestyle, I still haven’t lost any weight)
Magnification/awfulising – blowing things out of proportion (This new exercise regime is really terrible)
Perfectionism – expecting myself or others to be perfect (I must achieve my health goals otherwise it will be really awful)
Blame (It’s my partner’s fault that I drink too much alcohol)
Personalisation (It’s all my fault)
Minimisation (It’s only one cream cake and a doughnut)
Fortune-telling (I can see it all going wrong. I’ll be a butt of jokes)
Labelling or totally condemning oneself or another on the basis of an event or illness (Not achieving my goals proves I’m a total failure)
Fretting about how things should be instead of accepting and dealing with them as they are (My health programme should be a lot easier to tackle)
Low frustration tolerance (I really can’t stand this hard work any more – I need a cigarette now to take the edge off things)
Using ultimatum and demanding words such as shoulds, musts (My partner really should support my attempt to stop smoking, or: I should eat all the food on my plate)
Not being bothered (I can’t be bothered to continue this health programme)
Deservingness/entitlement (It’s been a tough day – I deserve a good drink)
Permission/permissive beliefs (It’s okay to treat myself to more chocolate)
Compensatory beliefs (As I eat a healthy diet, it doesn’t matter if I have an extra glass)
Case study: All-or-nothing thinking
Client: Since I last saw you, I’ve haven’t walked as much as we’d planned. I’ve totally wrecked my exercise regime! What’s the point of continuing?
Health coach: Do you recall what type of thinking this is?
Client: Not sure.
Health coach: You may recognise it from the list I gave you last time. Here’s another copy.
Client: Probably the first one on the list. All-or-nothing thinking.
Health coach: I agree. Let’s examine this a bit more in-depth. Are you still doing some walking in your lunch breaks each day?
Client: About 15 to 20 minutes each day.
Health coach: Which is good, however, I realise it’s not the 30-minute walking programme you devised for yourself.
Client: Yeah, and that’s the problem!
Health coach: I wonder if it is the problem? Let’s focus on you, in your own words, having “wrecked your exercise regime”. How does it logically follow that you have totally wrecked your exercise regime by not keeping rigidly to it since our last meeting? (Socratic question based on logic)
Client: Not sure.
Health coach Logically, what would you have to do to wreck your regime?
Client: I suppose, never do it again.
Health coach: Does walking 15 to 20 minutes each day instead of 30 for about two weeks, mean you have wrecked your exercise regime?
Client: I suppose not. It’s not as much as I’d hoped.
Health coach: Yes, that’s true, but at least you are still doing more daily exercise then you were a month ago. What could you think instead?
(Encouraging the client to develop a HET)
Client: Perhaps that I’m still keeping to my exercise regime, but I could do a bit more every day.
Health coach: Sounds right to me. Your next idea was also all-or-nothing thinking. You asked: “What’s the point of continuing?” Do you find that idea motivating or demotivating? (Pragmatic question)
Client: Demotivating, I suppose.
Health coach: What could you think instead if you want to motivate yourself? (Encouraging the client to develop a HET)
Client: There are lot of benefits to me if I continue.
Health coach: Such as? (Coach prepares to write down the benefits to encourage the client to maintain the programme)
Client: Well, I feel good when I walk; it gives me a break from the office; it’s good for my health.
Health coach: I agree, and there are probably others too, such as it gives you time to think about solving problems at work. So, to summarise, you are still largely keeping to your exercise regime, but you could do a bit more every day; and there are good reasons to continue. However, let’s go back to your original goal and see if walking for 30 minutes every lunch time, was a realistic goal. Perhaps you could do some walking after work
as well. (Having dealt with the HITs the coach then decides to re-examine the goal just in case it needs revision.)
Coaching at Work, Volume 7, Issue 5