Culinary Medicine Coaching Module 1
UNIT 1 |
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Empowering People to Start Lifestyle Change
The 5 A's of Behavior Change The Transtheoretical Model of Change What is Motivational Interviewing? Article Review
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GOALS
OBJECTIVES
LEADING QUESTIONS
REFERENCES
- Encourage the students to think uniquely about how to empower people to start an effective lifestyle modification.
- Consider the role of education in negotiating behavior change.
- Explain the five As of behavior change counseling
- Introduce the Transtheoretical Model of Change
OBJECTIVES
- To describe lifestyle medicine coaching strategies
- To appreciate the principles of essential to being a coach
- To lay hold of the five As of behavior change counseling
- To understand the application of the six stages of change described in the Transtheoretical model of Change
LEADING QUESTIONS
- What is the effective way of dealing with patient's faulty lifestyle behavior?
- How can an effective coach lead patients to start an effective lifestyle change?
- How can five As and the six stages of change be incorporated in assessing patient's readiness and deciding on the coaching approach accordingly?
REFERENCES
- Lifestyle Medicine Handbook, Beth Frates, MD
- Lifestyle Medicine Core Competencies, ACLM & ACPM
Empowering People to Start Lifestyle Change
Culinary coaching is a vital part of Culinary Medicine. Eating is a behavior that has infinite pathways in the brain that could be influenced and directed towards healthy patterns and eventually achieve positive health outcomes. Behavior can never be changed overnight and that is a fact that we always deal in culinary medicine. In this first section we will be discussing some basic principles necessary for any CulinaryMD specialist. We first deal with patient's/client's behavior process before we an finally introduce certain plans for their specific health concerns.
Coaching is the key verb in lifestyle medicine. It is the way to evoke behavior change. There are distinct differences between being a coach and being an expert. As such, coaches have many tools in their toolbox. They use a whole different approach to the patient. This module will introduce some of the most important tools that empower “doing” aspects of coaching. Before discussing behavior change and how to apply coaching strategies, it is important to understand that the underlying focus of culinary medicine practitioners in to help individuals and families adopt and sustain healthy behaviors that affect their health and quality of life. What is quality of life? In that regard, one commonly accepted definition of this subjective factor is that it is the patient’s ability to enjoy normal, routine everyday activities. In coaching relationship, the goal is to empower people to make changes that lead them to their optimal level of health and wellness. It is also equally important to assess a person's confidence on engaging with a certain behavior change. This will be the tool that coaches are guided in dealing and motivating a person to go from the first step of change towards achieving the goal.
Readiness Ruler
The Readiness Ruler, developed by Rollnick and used extensively in general medical settings, is a simple method for determining clients' readiness to change by asking where they are on a scale of 1 to 10. The lower numbers indicate less readiness, and the higher numbers indicate greater readiness for change. Depending on how ready to change clients think they are, the conversation can take different directions. For those who rate themselves as "not ready" (0 to 3), some clinicians suggest expressing concern, offering information, and providing support and follow up. For those who are unsure (4 to 7), explore the positive and negative aspects of treatment. For clients who are ready for change (8 to 10), help plan action, identify resources, and convey hope (Bernstein et al., 1997a). As clients continue in treatment, you can use the ruler periodically to monitor how motivation changes as treatment progresses. Remember that clients can move both forward and backward. Also, helping clients move forward, even if they never reach a decision making or action stage, is an acceptable outcome. Most clients cycle through the change stages several times, sometimes spiraling up and sometimes down, before they settle into treatment or stable recovery. One significant feature of the readiness to change scale is that clients assess their own readiness by marking the ruler or voicing a number.
The Readiness Ruler, developed by Rollnick and used extensively in general medical settings, is a simple method for determining clients' readiness to change by asking where they are on a scale of 1 to 10. The lower numbers indicate less readiness, and the higher numbers indicate greater readiness for change. Depending on how ready to change clients think they are, the conversation can take different directions. For those who rate themselves as "not ready" (0 to 3), some clinicians suggest expressing concern, offering information, and providing support and follow up. For those who are unsure (4 to 7), explore the positive and negative aspects of treatment. For clients who are ready for change (8 to 10), help plan action, identify resources, and convey hope (Bernstein et al., 1997a). As clients continue in treatment, you can use the ruler periodically to monitor how motivation changes as treatment progresses. Remember that clients can move both forward and backward. Also, helping clients move forward, even if they never reach a decision making or action stage, is an acceptable outcome. Most clients cycle through the change stages several times, sometimes spiraling up and sometimes down, before they settle into treatment or stable recovery. One significant feature of the readiness to change scale is that clients assess their own readiness by marking the ruler or voicing a number.
THE 5 A's IN BEHAVIOR CHANGE COACHING
Behaviour change has focused on five A’s: assess, advice, agree, assist, and arrange. The all-important step of agreeing is included in the five A’s. The patient needs to agree with the treatment plan and the plan for behaviour change of the plan has any chance of working and being implemented.
Assess
Lifestyle medicine practitioners need to assess the patient on multiple levels. Knowing what is going on inside the body by checking blood tests in often useful. Lab tests including fasting cholesterol, LDL cholesterol, C-reactive protein, iron, hemoglobin A1c (for glucose control), thyroid function test can help the practitioner assess the patient.
Assessing the patient’s readiness to change is another important factor, one that is discussed in the section of this unit on the Transtheoretical Model of Change (TTM). Inquiring about the patient’s understanding of their disease process or risk for disease can help the practitioner about what education might be useful to the patient. For example, what are the patient’s motivators for change, both intrinsic (internal like wanting to feel more energetic) and extrinsic (wanting to lose weight to fir into a bathing suit)? Other valuable questions include, “Where are you now in terms of your lifestyle? Or, “What information are you seeking today?”
The answers to such questions can help the practitioner to better understand the patient. How confident is the patient in change? How important is the change to the patient? What obstacles are in the way? What are the patient’s strengths? Where does the patient see themselves in 10 years? What is the difference between where they are now and where they want to be? Assessing the patient by asking these questions will help the practitioner better serve the patient and co-create a plan that has meaning for that patient.
Advice
Lifestyle medicine practitioners will need to give their opinions and advise the patient on the best way forward. For example, after noting that a patient is obese by BMI, the practitioners will need to share that information in a non-judgmental and open minded way with language such as “According to your BMI you fall into the obese category. What do you think about that?” If the patient says “It’s no big deal. I have always been like this, and my family is like this,” Then the practitioner can advise the patient with, “There has been a lot of research on the role of obesity on developing different disease, and reaching a healthy BMI is important for your body.” A follow-up question such as “What do you think you can do to reach a healthy BMI?” will help keep the consultation a conversation rather than a lecture. If a patient is smoking, a lifestyle medicine practitioner will need to advice that patient, “One of the best things you could do for your health is to quit smoking.” Following up with a question such as “How are you feeling about your smoking?” will engage the patient to transition the advice into conversation. The goal of advice-giving is to lay out the medical facts and to open the door for a conversation about them.
Agree
This A is probably the most important in the five A’s. The patient needs to agree with a plan for change. After the assessment, advice, and discussion, the practitioner and patient work to co-create a plan for moving forward. This is co-creation because the patient needs buy in and needs to feel some responsibility for taking action steps to make a change. By using the coach-like approach, the lifestyle medicine practitioner will be collaborative, when dealing with the patient. This step will occur naturally.
Assist
The lifestyle medicine practitioner assists the patient in order to help make the co-created plan a reality. The assistance can come in the form of setting a SMART goal, helping to make sure that the goal is specific, measurable, action oriented, realistic, and time-sensitive. The practitioner could also help the patient to find resources that might be helpful to them, for example, local YMCAs, community classes, Farmer’s markets, or online stress management classes that might be of value.
Arrange
The lifestyle medicine practitioner needs to arrange for follow-up with the patient. If plans are co-created, and there is no follow-up, then, the patient could forget about the plan and, thus, no progress will be made. By arranging follow-up the practitioner is signaling to the patient that they will be held accountable for the plan, and there will be a check-in. It also tells the patient that someone cares. Someone will be asking about the plan, the goals, and the progress. This approach is a way of making the patient feel important and valued.
The Transtheoretical Model of Change (TTM)
Renowned University of Rhode Island psychologist Dr. James Prochaska has been studying behaviour change since the 1980s. His father, who was an alcoholic, died of complications of the disease. After that, Dr. Prochaska was determined to understand alcoholism and addiction so that he could help others avoid the suffering that his father and family experienced. Dr. Prochaska, working hard to try to solve the mystery of addiction, made tremendous progress in this area.
After studying addiction for more than three decades, Prochaska and his colleagues created the stages of change model known as the Transtheoretical Model of Change (TTM). This model has enabled healthcare providers to be more effective in their behaviour-change counselling of patients who suffer with addiction, as well as those individuals seeking to change their unhealthy behaviours. The model allows practitioners to identify a patient’s current stage of change and then target the consultation and counselling to that person with stage-appropriate processes. As a result, the practitioner is able to meet the patient where they are during the consultation. Rather than talk at them, they can talk with them.
There are six stages of change: pre-contemplation, contemplation, preparation, action, maintenance, and termination. The authors have suggested specific interventions that have seen found to be effective for the various stages. While the interventions or processes can be employed at many different stage, ideally, practitioners should try experiential for pre-contemplators and contemplators and behaviour processes for those patients in late stages (preparation, action, maintenance, and termination).
Pre-contemplation
Pre-contemplators are those individuals who are resistant to change. As such, they are not intending to take any action in the foreseeable future. They may be either uninformed, or under-informed about the specific behaviour. The interventions and processes suggested for patients in this stage are experiential and cognitive. For example, a pre-contemplator might make statements, such as “I’m not going to do it.” “I can’t exercise. I have absolutely no time. I mean, you don’t understand my schedule. It’s crazy. I couldn’t possibly exercise.” Or, “I refuse to quit smoking.”
For individuals who are pre-contemplative, practitioners can use consciousness-raising efforts. For example, they could be asked, “Are you familiar with the risks of smoking? Specifically, did you know it was connected to erectile dysfunction?” Patients might say “yes,” they might say “no.” The key is to make the information personally relatable and relevant. If the patient responds with “Well no, what d you mean?”, for instance, the practitioner can share knowledge about the particular topic. As a rule, after agreeing or granting permission to the practitioner to explain the facts further, the patient will likely be more receptive to education and counselling.
The next step may be to suggest how the issue may impact others – environmental reevaluation. For example, if the patient is a mom who eats a lot of junk food and keeps it in the kitchen cabinets at home, the practitioner might ask, “What effect does your eating have on your immediate family?” In turn if the patient is a doctor who eats lots of sweets and brings leftover cookies and treats to the office for both the patients and staff, the question could be asked, “What is the health effect of this behaviour on those individuals in the office?”
Another TTM technique is dramatic relief, which involves paying attention to feelings. This stage involves inviting the pre-contemplator to feel something emotionally about the unhealthy actions they are taking. For example, sharing stories of patients who actually quit smoking and what happened when they quit. Explaining how the lives of those patients changed is one way to help a patient visualize a role model and feel the rewards of quitting – before actually quitting. An opposite approach to this technique would be to describe the ill effects of continuing to smoke, perhaps by showing photos of cancer survivors or sharing a comparative model of the lungs of smokers versus the lungs of non-smokers. The underlying premise of this method is to evoke emotion – e.g., fear, sadness, excitement, surprise, disgust, or anger – and invite the patient to pay close attention to these feelings. Having patients idenfying their feelings, explain why they feel that way, and what they could do to feel differently is a useful strategy with pre-contemplators.
It is also helpful when counselling pre-contemplators to acknowledge social trends. This step elicits the social liberation process in the TTM. This process brings in the outside forces that influence the patient in their strategy for pre-contemplators.
No person is completely free of influence. Social trends are well-know to affect the individuals living in certain environments and cultures.
Contemplation
The next TTM stage is the contemplation stage. Patients in this stage may be thinking “Hmm, I’ve been thinking about changing, but I just don’t know. I don’t think I can do it. I’m not sure. Imean I want to do it, but then again I don’t want to do it.”
This stage is marked by ambivalence. This is another stage in which motivational interviewing is an appropriate tool to use. People can also be in a state of what is called chronic contemplation. For example, they may proclaim (for years, sometimes) “I know I should exercise regularly. I know it’s really good for me. I just can’t get started.”
The key feature of contemplation is that the patients are actually thinking about their situation. Whereas, in pre-contemplation, patients are saying, “No way!” contemplators are saying, “I’m thinking about making a change.” For contemplators, the pros of change often equal the cons of change, or the pros may be less than the cons the way they are viewing it. That is what may make it difficult for them to decide to change.
Similar to the pre-contemplative stage, the processes suggested for contemplators are experiential and cognitive. They may include the same techniques used with precontemplators, such as consciousness raising, environmental reevaluation, dramatic relief, and social liberation (social trends). In addition, the cognitive process of self-reevaluation is a suggested strategy to use with contemplators. Self-reevaluation helps patients create a new self-image. For example, the practitioner might ask, “Imagine you were free from smoking. How would you feel about yourself? How would you feel about yourself? How would you feel each day? How would that change the way you feel in the morning? How would it change your life?”
Asking such questions, with an intention of connecting the answers to the core values of the patients, can be incredibly motivating. It allows the patient to see how new self-image or a reevaluation of themselves, without the unhealthy behaviours, will enable them to be their authentic selves. For example, if they are contemplating change, a practitioner can say, “Well, I know that your family is really, really important to you. Tell me about how changing this behaviour would affect your feeling about how you care for your family.”
Preparation
The next stage in the TTM is preparation. Patients in this stage say, “I want to do this, I’m going to do this. I am planning to do this soon.” It is almost like they are saying “I just need a good plan. I just need confidence.” As such, the people in the preparation stage of change are intending to take action within the next month.
Self-liberation, a recommended process for this stage, involves making commitment to change. If a patient tells a friend, “I’m going to start exercising this week,” that friend is likely going to ask about it the following week. By committing to change verbally or writing it down, patients make the behaviour or goal real for themselves, as well as for other individuals hearing or reading the commitment. This is liberating because the desire and intention is no longer bottled up inside the patient. Rather, it is expressed and freed from the confinements of the patient’s mind. A statement of self-liberation sounds like, “I’m going to start on this walking program at the YMCA on Tuesday at 10 a.m.” The statement is specific concerning when, where, and how the behaviour is going to be accomplished.
In the preparation stage, helping relationships are useful. Since the patient is ready and willing to change, identifying supportive people and relationships can be the difference between remaining in the preparation stage and moving into the action stage. For example, if the patient has friends who also want to change their eating patterns and adopt a whole-food, plant-based diet, then connecting with those friends and creating plan together will increase the chances of success. Not only will the patient have partners who are just as interested in the process as the patient, they will also have built-in accountability. The partners can talk about recipes together, grocery shop with each other, and perhaps, share meals together.
Counter-conditioning (or substitutions) represents a third important process for people in the preparation stage. If patients are used to going to fast-food restaurant after work each night, and they want to adopt a whole-food, plant-based diet, there are several options for counter-conditioning available in such a scenario. One might be able to consider a fast food chain that has a vegetable burrito bowl or a healthier version of fast food as a substitution to start. There are chains that cater to people with allergies and food sensitivities, as well as to vegetarians and vegans. These chains offer several whole food, plant-based options.
Being realistic about the substitutions is important. How likely is the patient to order a salad instead of a burger at their favorite fast food chain. The smell of the burger and fries may be too hard to resist, and going to the same location might just bring the patient into the old habit. So mapping out a different way home, one that avoids that fast-food chain leads the patient to a farmer’s market may have premade healthy options that are whole foods and plant-based, which might be a good substitute to begin the change process. Another alternative might be to buy veggie burgers or bean burgers at the grocery store, instead of ordering hamburgers at a fast-food chain. In addition, buying sweet potato chain, would certainly be a healthier option. In all of these possibilities, the key point is that the preparation stage is a process that will take time to navigate through and will require many small steps.
Action
Patients in the action stage of change have actually been engaging in the healthy behaviour for several weeks. However, just because these patients are undertaking the intended action does not mean the practitioner should ignore them. Importantly, these patients need specific counselling, as well, in order to encourage them to continue on to the maintenance phase of the TTM, because patients in the action stage can relapse and go right back into chronic contemplation. TTM is not a stepwise model for change, but rather, more similar to a spiral model.
In the action stage, the practitioner can use the techniques of helping relationships and counter-conditioning, when counseling the patient to encourage them to continue on with the healthy behaviour, in the same way these processes were used in the preparation stage. Additional processes that are recommended for those individuals in action stage include reinforcement management and stimulus control.
Reinforcement management involves using rewards to reinforce the positive behaviour. A practitioner can invite the patients to acknowledge the benefits of the newly adopted healthy behaviour by asking, “Now that you have been exercising for a couple of weeks, what have you noticed that is different?” Allowing the patients to express the changes that they notice in themselves gives them the opportunity to reflect on these changes and to appreciate them. Patients can then realize, “Wow I’m doing this. And I feel more energized, more focused at work, and I am sleeping better too.”
If the duration has been sufficiently (approximately a month or more), the practitioner can also point out any physical or lab changes, such as changes in body weight, waist circumference, blood pressure, or cholesterol levels. By acknowledging the health benefits, the patient receives an added incentive to continue the healthy behaviour.
Stimulus control is another important process in the action stage. Using the social ecological model of change, the practitioner can help the patient recognize the events, the people, the places, and the objects that encourage the newly adopted behaviour. Conversely, the practitioner can help the patient understand and appreciate the factor that tempt them to return to old unhealthy behaviours. Appreciating these various stimuli is critical to this stage of change.
To control the stimulus, patients must first recognize the triggers or cues that encourage the healthy habit, as well as those factors that encourage the unhealthy habit. After identifying the stimulus of the undesired behaviour, patients can create a plan to increase exposure to people, places, and events that encourage the new target behaviour. Patients can also avoid or rid themselves from the cues, triggers, and experiences that sabotage the efforts to change.
Maintenance
In the maintenance stage of TTM, patients have been in action for at least six months. On occasion, practitioners may be tempted to ignore these patients and assume that they do not need further assistance. The image of the spiral stairway, however, is a constant reminder to practitioners that the process of changed include slips, lapses, and relapses. It is therefore recommended that practitioners ask patients in the maintenance stage about the desired healthy habit. For someone who is jogger, for example, the conversation might involve the following: “How is the jogging going? Remind me what you are going to do in the winter, when the snow starts to fall.”
In this example, the practitioner is looking ahead at the potential barriers and obstacles confronting the patient, as well as helping the patient to strategize solutions that address those challenges. Asking the patient to share their motivation for continuing to jog will remind both the patient and the practitioner of the importance of this activity to the patient. For example, the practitioner might say, “What is motivating you to keep on going? Wow, you’ve been doing this for a long time. Congratulations! I’d love to hear more about how you do this.” The patient may then respond that their motivator is stress relief right now. Motivators change, however, and tapping into the patient’s current motivators can be illuminating.
Reviewing the benefits of the new behaviour, such as jogging, as well as the physical and lab changes that occur as a result of engaging in the action stage, can also be used in maintenance. Furthermore, stimulus control can be useful in this stage as well.
Termination
Termination is the sixth step. In the termination stage, patients have no temptation to return to the old unhealthy habit. “The termination stage is the ultimate goal for all changers….. your behaviour will never return…” Over the years, the thoughts and ideas about this stage have evolved. Not everyone discusses or works with this stage. Many individuals feel that smokers are in the maintenance stage forever, as are people who start exercising. In reality, it seems that most behavior change requires some sort of maintenance. More often than not, it is something that the patients are going to continue striving to do or the rest of their lives.
BASIC TTM AXIOMS
- You cannot get people to change unless they truly want to change.
- You cannot force people to listen to you, if they do not want to listen.
- If you get resistance from a patient, you should let them know you are here for them when they are ready.
- The best first step is to listen to your patient. Not only will you build rapport, but you will be better able to understand where they actually are in the process of change.
- You are a facilitator to the patients’ own discoveries. While suggestions, knowledge, and prompts may be very helpful to expand and conversation, patient are the experts in themselves and will be able to tell you what their goals are and what they will be capable of doing.
- Though patients may turn to you for motivation, true motivation comes from their desire to make the change for themselves. While you can provide accountability, expertise, and observations (both concerning the positive effects of the change and the negative barriers they may be experiencing), the underlying goal is to be help them find their intrinsic motivators.
What is Motivational Interviewing?
Motivational interviewing (MI) is a critical technique that lifestyle medicine practitioners need to master. In general, MI is defined as a collaborative conversation style for strengthening an individual’s motivation and commitment to change.
The underlying premise is that while people want to change, they also want to stay the same, because it is easier and requires less effort. MI is designed to strengthen an individual’s motivation for, and commitment to, achieving a specific goal. It fosters this situation by using techniques that focus on listening and exploring a person’s reasons for change within an atmosphere of acceptance and compassion. One of the main objectives of MI is to elicit change talk, to have the patients state the reasons that it is good for them to change so that they end up convincing themselves of the need to change.
Inviting patients to list the pros and cons of a behaviour is a constructive way for them to weigh their options concerning whether or not to change. This process is referred to as creating decisional balance and is often very enlightening for patients. For example, one MI tactic that sometimes startles smokers is for practitioners to ask, “Tell me all the pros about smoking.” While this effort may not elicit change talk, it helps patients to evaluate their thoughts and feelings about smoking.
Article Review
At the end of your readings, create a reflective essay describing salient points you learned from each article.
Unit 1 Task
So far, you have learned about the basic principles in dealing with a person's behavior and understanding the transtheoretical model of change. Create a REFLECTIVE ESSAY focusing on the integration of the lesson discussed above in the context of culinary medicine.