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James Prochaska, PhD, recognized that some people were ready to change and others were not, and that different strategies had to be used for people in different stages of readiness. After surveying a wide variety of different psychotherapeutic models, Prochaska and his collaborators put together the TTM to identify what processes worked best for people in different stages of change. Carlo DiClemente, in his PhD dissertation, identified ten such processes that describe what people actually do to change. Five are cognitive and five are behavioral processes of change.
Processes of Change
Cognitive processes encompass a wide range of reflective-learning processes in which people are sorting out their thoughts, feelings, and desires regarding a particular health-promoting change. These processes, which often take place over a period of several months or even years, include:
(e.g., medical and lifestyle) of doing a behavior. Being Moved Emotionally: Taking to heart the health effects of a behavior and using them to ignite your drive to change. Considering How Your Behavior Affects Others: For example, thinking through what your children may be learning from watching you per-form a behavior. Self-Image: Connecting the dots and seeking congruence between one’s vision, values, and behaviors to enhance integrity. Social Norms: Connecting and talking with like-minded people who are all working on the same behavior (e.g., a support or special-interest group). Behavioral processes encompass a wide range of action-oriented learning processes in which people are experimenting with new health-promoting behaviors and adopting the ones that work.
These processes include:
Making a Commitment:
For example, writing down exactly what new behavior will be done and when.
- Using Cues: For example, designing environmental reminders to do what is planned.
- Using Substitution: Replacing an old health risky behavior with a new health-promoting behavior (e.g., substituting carrot sticks or a straw for a cigarette).
- Social Support: Recruiting family and friends to help with behavior change by specifically asking each of them to consider the particular thing you would like them to do for you. This requires clients to think carefully about what they would like someone to do and then to ask the person on their support team to do it.
- Rewards: Setting up ways to be rewarded or rewarding yourself for completing your weekly action goals.
An effective way to engage clients in the processes of change, especially the cognitive processes, is to get them to weigh the pros and cons of a particular behavior or behavioral change. Known as a Decisional Balance, such weighing increases the chance of successful behavior change by taking into consideration:
The Pros or gains for self, gains for others, approval of others, and self-approval. The Cons or losses for self, losses for others, disapproval of others, and self-disapproval.
Pros/benefits/motivators are the good things about doing a new healthy behavior. They are what you will get if you do the new healthy behavior. It is the coach’s job to help a client move from a general, non-specific pro such as “I want to stop smoking for my health, so I won’t get sick down the road” to a specific, personal, positive motivator such as “I really want to stop smoking because my children will not allow my grandchildren to come into my house because I smoke, and I want to be able to bake cookies with my grandchildren.”
Cons/barriers/challenges are things that make it hard to do a new healthy behavior. By getting clients to sort through their barriers, you can assist them to discover that some barriers are real and only time will change them, some are excuses, and some can be overcome by a strong enough pro or motivator. For example, the young executive who was working 18 hours a day in his first job trying to make a mark for himself had absolutely no time to exercise regularly until an attractive young woman who worked out regularly joined his firm; he somehow found the time to go to the gym because he wanted to get to know her. Some barriers can be overcome by a strong enough motivator.
When people are thinking about changing a behavior, they can ask them-selves these three basic questions:
- Why do I want to try and change the behavior? (pros)
- Why shouldn’t I try to change the behavior? (cons)
- What would it take for me to change the behavior? (What’s my strategy to overcome my cons?)
Clients in the “I Can’t” stage who are totally focused on al barriers and all the reasons that they cannot make a change can be praised for knowing their barriers. If the three tasks of an early-stage person are finding a motivator, knowing their barriers, and coming up with some possible solutions, the “I Can’t” person has one of the three tasks completed. They are acutely aware of their barriers. The work of coaching is to make sure the other two tasks get done.
Over the past 25 years, researchers have found that the pros have to outweigh the cons for someone to actually do a new behavior successfully. This means it is very important to help early-stage people who have not yet started to do a behavior to find personally salient, specific, positive pros or motivators and to honestly sort out their cons.
Self-Efficacy
The point of the TTM, and of health, fitness, and wellness coaching in general, is to increase a client’s sense of self-efficacy, or “the belief that one has the capability to initiate or sustain a desired behavior (the exercise of control).” Self-efficacy, described and explored by the seminal work of Albert Bandura (1977, 1986, 1997), is such a core concept in coaching that we devote an entire section to its understanding and application.
Simply put, however, self-efficacy describes the circular relationship between belief and action: the more you believe you can do something, the more likely you will do it; the more you do something successfully, the more you believe that you will be able to do it again. The opposite is also true: the more you believe that you cannot do something, the less likely you will do it; the more you do something unsuccessfully, the less you believe that you will be able to do it again. In other words, to quote an old adage, “nothing succeeds like success.”
As a holistic life coach, holistic nutrition coach, or any coach for that matter, it is therefore very important that you do not allow clients to set inappropriate goals that they may fail at, possibly setting up a series of failures. That’s also why it is so important to correctly determine a client’s stage or readiness to change (e.g., whether you are working with an “I may” or an “I will” person). It is risky to let an “I may” person set late-stage behavioral goals. The appropriate goals for “I may” persons are thinking and feeling goals— connecting with their positive core, finding motivators, knowing barriers, and coming up with possible solutions. They are not yet ready to experiment with activities as is the “I will” person.
The way to tell the difference between an “I may” person and an “I will” person is to ask him or her these questions:
- Why are you making this change now?
- What do you want to get from making the change? (motivator)
- What is going to get in the way? (barriers)
- What are some of the things you might try to overcome the barriers? (possible solutions)
To protect against clients setting inappropriate goals that they may fail at, you can ask clients, after they have set a weekly goal, “On a scale of 0 to 10, how confident are you that you will be able to accomplish this goal this week?” If you hear an answer of 7 or above, you can be reasonably confident that the client will succeed. If you hear a lower score, you may want to share with the client the concern about this goal being at risk for failure. You can explain the circular nature of confidence and ask about how they could improve their confidence rating. Is it by altering the goal or scrapping it altogether and starting over? When it comes to self-efficacy, it’s crucial to not over-promise and under-deliver.
Coaches can unduly influence a client by their energy and enthusiasm. This can result in clients taking on goals that are more important to the coach than to the client. You want to avoid making suggestions that the client could interpret as being what the client is supposed to do or should do. If your client needs a suggestion, it may work well to brainstorm ideas together, taking turns to generate multiple suggestions. By asking clients to then choose from among the possibilities, decision making remains in the hands of the client, where it belongs.
Operant Conditioning
When clients have experienced some type of challenging situation and have had a lapse, your job as coach is to reframe this failure and turn it into a learning experience. Ask, “What can we learn from this experience? Who were you with? What were you doing? Where were you? How were you feeling? What could you do differently next time?”Assist clients to come up with a relapse prevention plan so they are ready the next time that the challenging situation arises.
Another way to engage clients in the processes of change, especially the behavioral processes, is to get them to focus on the relationship of a behavior and its consequences. Known as operant conditioning, or learning through positive and negative reinforcement, it is a form of learning that takes place when an instance of spontaneous behavior is either reinforced or discouraged by its consequences. The principles involved have had a strong influence on behavior as well as on other kinds of therapy.
Successful operant conditioning looks for the antecedent conditions that may trigger an undesired behavior. For example, missing breakfast may lead to overeating at lunch, which may lead to feelings of guilt, which may lead to irritability. This irritability may lead to abandonment of any improved eating habits for that day. The end result can be an ice cream binge after dinner. When a behavior chain is identified, assisting clients to alter a behavior earlier in the chain instead of later can generate significant shifts and benefits.
It is often easier to manipulate the antecedents than to modify the consequences or behaviors. Examples of antecedent conditions could include a long drive to get to the gym, an unpleasant workout environment, driving by a favorite ice cream shop, a particularly stressful day, or negative self-talk. For example, stressful workdays and self-statements, such as “I am overwhelmed and can’t deal with everything,” may lead to overeating at dinnertime on a continual basis. It may be helpful to create a goal that helps clients relieve some of their stress during the day or before eating, in addition to their goals that relate to eating.
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