It’s really not that bad…

March is Colon Cancer Awareness Month and I am writing today to try to convince those of you who have been putting off your colonoscopy that it is really not that bad. It is a relatively simple procedure that could save your life – the minor inconveniences involved with the prep will be worth the peace of mind if you are able to prevent or catch colon cancer in its early stages.

A few quick facts about colon (or colorectal) cancer:

  • Colorectal cancer is the second leading cause of death in men and women.
  • One in 20 people will be diagnosed with colorectal cancer.
  • One in three people are not up to date on their screenings.
  • Family history is a strong risk factor.
  • Colon cancer is preventable and treatable if detected early.
  • If you are at least 50 years old with no symptoms, your screening is normally covered by insurance.

(Source: https://www.cdc.gov/cancer/colorectal/pdf/no_pocket_brochure.pdf)

Personal experience

I will be 46 in June and have already had three colonoscopies, so I am speaking from personal experience. My first one was at age 34 and came about as a result of some concerning symptoms (blood in my stool) and a family history of colon cancer (maternal grandfather). I saw my primary care physician first and given the above factors, she sent me to a gastroenterologist. Both physicians suspected that it was just hemorrhoids, but my GI doctor recommended a colonoscopy due to my family history. Sure, I was a little apprehensive at first, but I wanted to be sure that it was not something serious.

I’ll spare you most of the details but as you’ve probably heard, the prep is the worst part. You have to avoid certain foods a few days prior to the procedure and then fast starting around noon the day before your procedure. Then you have to drink a large volume of the prep solution over several hours to help clear out your system. I can say that the manufacturers are working to make it taste better – the solution I used for my most recent screening last year was the best of the three that I have had. They are also working to make the prep easier – there are several options including oral medications and a “split” prep process where you drink some of the solution the night before and finish it the next morning.

The colonoscopy itself is rather simple. Most patients are sedated for the procedure – the anesthesiologist gives you a nice dose of propofol or similar sedative in your IV and you are out before you can count to five. Next thing you know, they are waking you up and bringing you to the recovery area. Your gastroenterologist will likely provide you with a procedure report including some pictures of your colon (I personally think it’s kind of cool to see what it looks like inside!). If there were any polyps that needed to be biopsied, you may need to wait a week or so to get the results back.

Most people need a colonoscopy every 10 years, but it may depend on what the physician finds. In my case, I was advised to come back in five years after the first one as I had some benign polyps (and the family history risk factor). The same thing happened after my second one. But at my last one in 2018, I was polyp free and thus, can wait 10 years before my next one (unless of course I have any symptoms or warning signs that would warrant coming in sooner). As much as I might fuss about the inconvenience of the prep process, it really is worth it knowing I am doing everything I can to help prevent colon cancer or increase my chances of survival if I were diagnosed with it.

A quick note about your colon cancer screening options:

There are stool-based tests that are non-invasive and do not require any special diet or bowel preparation. These tests are usually recommended for people who have an average risk for colorectal cancer: no personal history of pre-cancerous polyps, no colorectal cancer that runs in the family, or no other risk factors. However, if the test shows abnormal signs of blood or a possible cancer or pre-cancer, a colonoscopy will be needed anyway to confirm the result and to remove any abnormal findings or polyps. Thus, it might be best to skip the stool-based test and just have the colonoscopy. Bottom line: consult with your health care provider to determine the best screening test for you.

Now if you’ll excuse me, I need to go remind my husband, who just turned 50 at the end of February, that it is time for his annual physical and a referral for his first colonoscopy!

 

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Maintaining the gains

As I discussed in my previous post, the path to change is seldom straight and easy. Even after a client has succeeded in sustaining their chosen health behavior over a period of months, they may still be susceptible to lapses or minor slips. During those times, it is critical for a coach to continue offering support and help the client determine what they have learned from their experience.

Maintenance occurs when a client has been regularly practicing the new behavior or action with no more than a few lapses or an occasional relapse after which they quickly and successfully return to regular practice. What started out as a goal has become a new habit. At that time, there are a few pathways for the client to consider:

 

  • The client may be ready to explore deeper commitment in the same focus area. For example, a client who went from being inactive to walking 3 days/week may wish to increase that practice to walking 5 days/week. Or they may choose to register for an activity such as a charity 5k walk.

 

  • The client may be ready to take on a new goal in a completely different area. Success in small goals often gives the client confidence to tackle more challenging behavior changes. For example, a client who is a casual smoker who increases their physical activity level may decide to quit smoking completely. Or a client who successfully reduces the amount of meat they consume may decide to go further and adopt a vegetarian or vegan diet.

 

  • The client may choose to complete coaching at this point now that they are able to successfully maintain the behavior change. Of course, the door is always open for them to return to coaching in the future if and when they want to take on a new focus area. However, I believe that the coaching process can also equip the client with the skills necessary to address future changes on their own. The skills they learn through the coaching process can be transferred to any habit or behavior they wish to change.

 

In the end, coaching is really a journey of self-discovery and exploration that empowers you, the individual, to achieve your highest level of health and wellbeing. There is no greater gift of self-love.

I hope you have enjoyed this series about the stages of the coaching process. Stay tuned for future posts about your favorite health and wellness topics!

 

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Assessing Action

When the client is in the action stage, they are doing and learning and adjusting action steps based on that learning. They may face challenges or obstacles, some of which they may overcome, others which may trip them up at least temporarily. The path to change is rarely a straight one so support and encouragement are critical to helping clients along this journey.

The next step in the coaching process is to help clients assess their progress and determine how to continue moving forward. Some key tasks include:

  • Acknowledging client successes
  • Helping the client learn from their experience, whether they were fully successful, partially successful or not successful
  • Supporting the client in identifying any barriers to change and strategies to address those barriers
  • Determining how the client wants to move forward (e.g., initiating new actions or refining current action steps)

I typically encourage clients to fill out and return a brief coaching session prep form prior to their session. This form allows them to capture successes, challenges, lessons learned and what they want to focus on in their session. It helps both of us prepare for an effective session and gives us both insight into potential areas to address during the session.

At each session during the action stage, I typically check in with the client about how things went since the last session. There are usually three possible outcomes:

  • Action was completed successfully
  • Action was partially completed (some lapses occurred)
  • Action was unsuccessful (client was unable to accomplish plans or relapsed)

The approach I take with the client depends on the outcome achieved. For example:

If action was completed successfully, I typically:

  • Acknowledge the client’s success and help celebrate little or big “wins”
  • Explore what the client learned through their successes
  • Review where the client is in the process of reaching their long-term goal/outcome and their vision of optimal health and wellbeing
  • If client goal/outcome is not yet met, determine additional action steps needed to keep the client moving forward

If action was partially completed or some lapses occurred, I do most of the above but also:

  • Help the client explore what was different on the days they were successful and the days they were not
  • Review action steps to see if any adjustments need to be made
  • Explore with the client what they will do if they encounter similar barriers or obstacles again

If action was unsuccessful in terms of the client’s plans and intent, I will:

  • Acknowledge the client’s attempts (if applicable) while recognizing the lack of meeting their goals
  • Assess what they learned from the experience and how to use that information going forward
  • Ask questions to determine whether we need to return to an earlier stage in the process (e.g., revisiting readiness to change or doing further work in preparing for action)

 

As I stated earlier, the path to change is seldom straight and easy. There will be twists and turns as well as successes and setbacks. A client may start off strong and then find themselves struggling when they face an unexpected obstacle. Another client may initially struggle to get momentum but then soar once they hit their stride. Each client is unique and thus, the process will be different for each one. It is my job as the coach to help the client navigate along this winding path, sharing in the peaks and valleys, reminding them that they have the power to change and make the choices necessary to reach their vision of health and wellbeing.

 

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Preparing for Action

When it comes to behavior change, setting a goal and identifying action steps is not always enough to ensure a client’s success. An often-overlooked step is helping the client prepare to take action. Taking the time to consider how and when a client will engage in their desired changes will increase the likelihood of the client successfully completing their action steps.

There are four primary strategies that I use when helping clients prepare for action including:

  • Exploring a typical day or week
  • Exploring potential barriers or challenges
  • Creating back-up plans
  • Establishing accountability

Let’s look at how each of these can help a client be as successful as possible.

Exploring a typical day or week

It is often easy for clients to articulate action steps when they are discussing the desired changes in general terms. However, we know that making changes in real life is not always as easy as it sounds. This is the main reason I often ask clients to get down into the details and think about what their schedule typically looks like, so they can realistically determine when and how they will complete their action steps. This allows the client to take a closer look at what is possible and what may need to change to allow for success.

For example, if a client would like to exercise more often, I might ask them to think about their current schedule and identify what days of the week would be best to add in the activity. Once they determine which days are best, we might delve in further to figure out what time of day will work best and/or where they will exercise. Exploring in detail like this often helps a client determine what is most realistic in accomplishing their action steps.

Exploring potential barriers or challenges

I have often found that this is one of the most helpful strategies to prepare clients for change. Many clients are excited to make changes and often assume that things will go according to their plan. But as we are all well aware, life often gets in the way and unexpected obstacles may arise. If the client does not prepare for these obstacles, their efforts may get sidetracked and they may get discouraged if they do not successfully complete their action steps.

After the client has identified their action steps, I will often ask something as simple as “What potential barriers or challenges could arise that might get in your way?” I may also explore what has kept them from succeeding in the past, if they have attempted this change before. Sometimes a perceived barrier may be a competing value. For example, a client may want to exercise at the gym after work but feel guilty that it will take time away from their family. If spending time with family is more important to the client, we might then explore how they can engage in physical activity that would involve the family, such as the whole family going for a walk after dinner.

Creating back-up plans

Once clients have identified potential barriers or obstacles to completing their action steps, it can be very helpful to establish back-up plans. Identifying a “Plan B” can help the client think through what they might do if they are not able to complete their action steps as intended. For example, the client who plans to walk with their family after dinner might need an alternative action if the weather is not conducive to being outside. They may want to have a family-friendly activity they can do inside, such as dancing to their favorite music.

Establishing accountability

A final key strategy in preparing for action is helping the client commit to taking action within a specific period of time and identifying the best way to hold themselves accountable to their plan. Many clients will rely on the coach as their accountability partner, but they may also have a friend, coworker or family member who can serve in that role. I typically ask the client how they want to be accountable to themselves and may inquire as to what worked well for them in the past.

Some clients choose to write things down and check them off once they’re completed. Others may want to track their progress on a calendar or even perhaps in an app. Still others may choose to reward themselves for accomplishing short- and long-term goals and actions. It is really up to the client to determine what will work best and they may want to experiment with different approaches until they find the method that works best. Going back to the client who plans to exercise with their family, they may find that keeping track of their activity on the family calendar is a fun way to get everyone engaged and also hold themselves accountable to their plan.

Once the client has thought through potential barriers, identified back-up plans and established accountability, it is time to take action. This is where the rubber hits the road! Next time, we will explore what happens once the client is in the action stage and reports back on their progress.

 

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Goal Setting and Action Steps

Once a client has selected a focus area and together we have determined that they are ready to make a change, we move into the goal setting stage. Setting goals is a critical part of the coaching process and one that deserves to be addressed thoroughly in order to help clients be successful. If this stage is not done thoroughly, the goals and actions the client chooses may not be appropriate for where they are in the change process. This can result in failed action and discouragement.

Goals/Outcomes

Typically, goals are set with a 3-6-month time period in mind. In this case, when we reference goals, we are talking about the desired outcome(s) clients hope to accomplish in that time frame. Research has shown that it typically takes about 3 months to make significant progress in changing behavior. This gives clients enough time to begin forming new and lasting changes in health behaviors yet is a short enough time frame to motivate them to make changes now.

Sometimes clients want to work on more than one goal at a time. It is important to help the client decide when they may be attempting to do too much. Clients may want to focus on one goal at a time in order to experience maximum success.  It is also important to help the client set goals that are a reasonable stretch. If it is too easy, the client may become bored and lose motivation. However, goals that are too difficult may lead to frustration and discouragement at the inability to change. An easy way to assess the right stretch is to gauge the client’s confidence around achieving the goal – ideally we want them to rate it between a 6-8 on a 10-point scale.

Action Steps

Many clients confuse their goals and desired outcomes with a plan or action steps. The goal or outcome is the destination. The plan is a series of specific action steps to help the client reach that destination. Once a client sets a goal, we then work together to identify the smaller steps necessary to achieve the larger goal. Many times, the action steps build from week to week with the client adding new action steps as they experience success and progress toward the goal.

Both the goal and action steps should follow the SMART formula and meet the following criteria:

Specific – the goal and action steps should be clear and concise. If they are too general or vague, it is difficult to know when they have been completed.

Measurable – the goal and action steps should be measurable so clients can track their progress. The client needs to have clear criteria for progress and completion. Monitoring progress on goals and action steps can be inspiring and motivating for many clients to continue with their changes.

Action-oriented (or Achievable) – the goal and action steps should be changes that are within the client’s ability to change and/or control. Otherwise, the client may struggle and become discouraged at the lack of progress.

Realistic – the goal and action steps should be largely within the client’s reach. It is best to work on small behavior or lifestyle changes.

Timed – the goal and action steps should be tied to a timetable for completion.

The best way to illustrate the SMART formula is with an example, such as a client who wants to lose weight. Setting a generic goal of “I want to lose weight” is not going to help the client move forward. There are too many unanswered questions – how much weight? By when? It may also make it harder to identify the action steps that will be necessary to achieve the goal.

A better example of this goal and potential action steps using the SMART formula might be:

Goal/desired outcome: I want to lose 15 pounds in 3 months.

Action step 1: I will schedule an appointment with my physician next week to ensure it is safe to start an exercise program.

Action step 2: I will purchase new sneakers next weekend so I can begin walking.

Action step 3: I will walk for 30 minutes in the morning 3 days a week.

Action step 4: I will drink 48 ounces of water per day.

In this scenario, the client would continue to modify and/or add action steps as they progress toward their goal. For example, if the client is successful at walking three days a week for a month, they may decide to increase that to five days a week and then eventually every day. Or they could choose to increase the duration of their walk to 45-60 minutes. On the other hand, if they have not exercised in some time and they find it difficult to walk for 30 minutes, they may need to cut back to 10 or 20 minutes until they build up their endurance.

The client may identify one or more actions steps to work on as part of their plan. It is up to the client to determine which steps should be done when. They may want to start with one action step that they are excited to take on. Or they may choose the action step that will have the greatest impact on achieving their goal. Some clients may want to start with one action step and achieve an easy “win” to build confidence, whereas others may be willing and able to take on more than one action at a time.

Once a goal and action steps are identified, it is important to help the client prepare for action in order to be as successful as possible. We will explore this critical step next time.

 

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Choosing a focus area and exploring readiness to change

So far, I have covered the first three stages of the health coaching process:

  • identifying the client’s vision for optimal health and wellbeing
  • exploring values and what is important to them about their health
  • assessing current health through Current and Desired States questionnaire and other available data such as lab and diagnostic tests or a health risk assessment

At this point, the client is usually ready to identify a focus area, i.e., a part of their vision of health they want to begin working on. This can be a particular domain from the Wheel of Health, such as nutrition or exercise, or it may be something like weight loss, which can encompass several areas of the Wheel. There are several factors that may influence where a client chooses to start, including:

  • the long-term importance of the focus area to them
  • the immediate benefits of making the desired change
  • the client’s current willingness to take on the challenge of the desired change

In my experience, that last factor typically plays a key role in how successful the client will be in making the change. That is why the next step in the process is so critical: assessing the client’s readiness to change. Just because a client has prioritized a focus area does not mean they are fully ready to make the change.

A client’s readiness to change can be influenced by many potential factors, but the two primary factors tend to be importance and confidence. Ideally, we want both of those factors to be relatively high before moving into goal setting and action steps. Oftentimes, clients want to jump right into action, but it will increase their chances of success to slow down and explore readiness to change before moving into action.

Typically, a client chooses a focus area because it is important to them at some level, but there may be other competing values or priorities that could interfere with the client’s attempt to change. And even if the selected focus area is of high importance, the client may have doubts about their ability to change. Perhaps they have tried in the past and failed, or they are not sure what steps they need to take to achieve the desired change. There are a number of strategies that coaches can use to assess readiness to change. Typically, we explore the importance of making the change before assessing confidence. After all, if it’s not important to the client, it is not really worth spending a lot of time on their confidence to change.

One of my favorite tools for exploring importance is a 1-10 number scale (with 1 being low importance and 10 being high). Asking the client to place the importance of making the change on a number scale allows them to think about all the factors that go into selecting the number. In general, a client is usually ready to move forward if they rank themselves as a 7 or higher. If a client ranks themselves lower than a 7, there are follow up questions I usually ask to explore the reasons why it is important for them to change. For example, if a client ranks themselves a 5, I may ask “What makes it a 5 versus a lower number like 3?” This allows the client to verbalize the reasons why they rated it as high as they did while also acknowledging any competing priorities that may keep it from being the most important area for change.

Another strategy for assessing the level of importance is to help the client explore the pros and cons of changing vs. staying the same. Having a client verbalize the pros and cons of changing may help them identify the positive benefits they will experience if they change. On the other hand, it may bring to light any competing priorities that could make it difficult for the client to change. All of this information is critical to helping the client determine if the focus area is of high enough importance to address at this time.

When the client determines that the change is important enough to move forward, the next step is to assess and support their confidence to make the change. In my work with clients, I have often found that importance is typically high, but confidence is usually on the low side. If a client is lacking in confidence around making the change, it can make the rest of the change process quite challenging. Thus, it is critical to adequately assess and help build the client’s confidence before moving into action. Lack of confidence often comes from the client’s previous attempts to change without success. For this reason, it is beneficial to acknowledge when the client has had at least partial success and more importantly, to help the client learn from the times they were both successful and unsuccessful.

Coaches use some of the same or similar strategies and tools to assess client confidence. For example, I often use the 1-10 number scale to assess confidence level (with 1 being low confidence and 10 being high). Again, we typically want the client’s confidence to be a 7 or 8 before moving into action. If a client ranks themselves lower, I will often ask one of the following questions:

  • “What makes it a {6} versus a lower number?”
  • “What would it take to increase your confidence from a {5} to a 7 or 8?”
  • “What number would it have to be for you to begin making the change?”

These questions can help a client verbalize what makes them confident about making the change as well as what challenges they believe may get in their way.

If a client’s confidence is low and they are not feeling ready to move into action, there are strategies a coach can use to help build their client’s confidence level. One of the most effective ways to do so is to explore the client’s strengths and past successes. Perhaps they have lost weight in the past and can tap into the tools and resources they previously used. Or this may be an opportunity to look at a client’s successes in other areas of their life and how those strengths and skills can apply to the current focus area.

If a client has made several attempts to change in the past without success, they may feel discouraged about attempting to change one more time. In a case like that, it is beneficial to have the client think about the time when they had the greatest amount of success, even if they did not accomplish all they hoped. If the client is concerned about barriers that prevented their success in the past, the coach can help the client strategize how to overcome those barriers should they arise again (this will be done in the action planning stage as well). Having a plan for addressing barriers may help increase the client’s confidence in attempting the desired change one more time.

After thoroughly exploring importance and confidence, the client and coach together will determine if the client is ready to move forward into Goal Setting and Action Steps. If confidence is still low, the client may want some time to think about it between sessions and then revisit confidence the next time. Or it may be that they need to consider a different focus area at this time. Even if the client and coach decide that moving forward with the current focus is the way to go, importance and confidence can shift throughout the coaching process. Thus, the coach may revisit either or both if they sense changes based on the client’s words or actions.

Assessing current health

Once a client has identified their vision of optimal health and wellbeing and why it is important for them to make changes in their health behaviors, it is helpful to perform a more comprehensive health assessment. This assessment can include input from a number of different sources including medical lab tests and diagnostics, a health risk assessment, recommendations from healthcare providers as well as any number of self-assessments around physical and mental health.

Even if a client comes to coaching with a specific focus area in mind, I find it is beneficial to have them complete a comprehensive self-assessment. Doing so may clarify what area(s) they most want to work on, or it may provide insight into areas that they did not realize were impacting their health. So many of our health behaviors are inter-connected, so taking a step back to look at the big picture can actually help a client identify the most important area(s) in need of change.

The self-assessment tool that I use with clients is the Current and Desired States Questionnaire. This self-assessment asks clients to rate their current and desired states of health on a scale of 1-10 for each area of the Wheel of Health. Doing so provides valuable input to clients as they prepare to select an area of health and wellbeing to focus on and set specific goals. In addition to rating each area, clients can document the reasons why they chose their current rating as well as what changes they could make to help them get to their desired level.

I usually give clients the questionnaire prior to our first meeting so they have time to complete it beforehand. This allows us to discuss the results in our time together. Before jumping into the specifics, I often begin with questions that ask the client about their experience completing the assessment and looking at their health in this way. For example, I may ask:

 

  • What was your experience in completing this assessment? What stood out most to you?
  • What, if anything, surprised you about your responses?

 

After discussing the general experience of completing the questionnaire, I then help the client explore specific areas on the assessment to help them prepare for the next step in the process, which is choosing a specific focus area. We often don’t have time to review each question in detail, so I typically use more general inquiry such as:

 

  • What are the areas in which you feel strong? What supports those areas of strength?
  • What are the areas where you would like to see some improvement or change?

 

Many times, clients will have more than one area in which they would like to improve. Given that behavior change takes time and can be difficult, I emphasize to clients that they do not have to take on all of their desired changes at one time. In fact, clients are strongly encouraged to work on only one area at a time. Studies have shown that the greatest success comes from choosing a focus area where the client will achieve results that are important to them and they are most likely to do well. Achieving a series of small wins in the early stages of behavior change can help a client stay motivated on their path to improved health and wellbeing.

As you can imagine, health assessment is not a static part of the coaching process. Depending on how long a client stays engaged in coaching, I will have them revisit and reassess their status along the way. Repeating the Current and Desired States Questionnaire at the end of the coaching process is also a wonderful way for the client to assess and celebrate the progress they have made and look at what changes they may want to continue with in the future.

Using one or more assessment tools is an excellent way to help clients clarify and prioritize what area of their health they want to focus on, particularly if there are multiple areas they want to change or improve. Self-assessment can also be an insightful part of the self-discovery journey that unfolds as part of the coaching experience.

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