Abstract
The aspiration of lifestyle medicine practitioners is a healthy population engaged daily in lifestyle behaviors that generate the vitality needed to live a good life. That said, we are aware that there is a high population prevalence of low readiness to change behavior. This article proposes that we can improve readiness to change by shifting our expert mindsets to coaching mindsets. We focus first on helping others mobilize resources that improve readiness to change, including motivation and confidence—rather than beginning with expert education and training on new skills and behaviors. We call this coaching activity tilling the (patient’s) ground, which then germinates an interest in a mindset shift from an unresolved state (e.g., I don’t have time to exercise) to a new state (e.g., I might feel better and be more productive, if I exercise). In a generative conversation, moving from unresolved to resolved improves confidence in behavior change. This mindset shift is called integration—connecting and integrating an unresolved state to new thoughts, ideas, or perspectives (the ah-hah experience). We use the ground zero metaphor in multiple ways, and invite readers to till their own ground, generate potential, and enable integration as role models.
Keywords: health and well-being coaching, mindfulness, motivation, integration
“We create space in our minds by setting aside all of our mental activity, including our own impulses to judge, fix, and rescue.”
Introduction
The field of lifestyle medicine aspires to move today’s population from poor health (40% of adults have 2 or more chronic diseases 1 ) to good health through daily engagement in lifestyle behaviors that treat and reverse chronic diseases and deliver the vitality needed for a high quality of life. Lifestyle medicine is best practiced as a team-based endeavor where multiple roles and coordinated interventions together, including coaching, deliver clinically significant results. 2 In the health and well-being coaching literature, robust studies demonstrate coaching efficacy,3-7 combining physician counseling and encouragement, lifestyle education and skills programs, and an ongoing coaching partnership.
One role of a coach is to help a patient translate lifestyle medicine treatment plans, education, and skills programs into daily life, aligned with their values, priorities, and readiness to change. Coaching programs typically involve at least 6, and sometimes ten or more 30–60 minute sessions 8 over 3–12 months. Positive study outcomes have shown to be durable for up to 4 years (blood pressure control) after a coaching program began. 7
The National Board of Health and Wellness Coaching defines health and wellness coaching: 9
“Health & wellness coaches support clients in activating internal strengths and external resources to make sustainable and healthy lifestyle behavior changes. Health and wellness coaches use a client-centered approach wherein clients decide their goals, engage in self-discovery or active learning processes, and self-monitor behaviors to increase accountability, all within the context of an interpersonal relationship with a health coach.”
The coaching profession in healthcare began in the US in the late 1990s and early 2000s, with pioneering practitioners in health coaching (Merberg), 10 integrative health coaching (Bark), 11 and wellness coaching (Arloski). 12 The first coaching school for health professionals (Wellcoaches Corporation in partnership with the American College of Sports Medicine) launched in 2002, creating and evaluating coaching protocols and coach training curriculum later published in the first coaching textbook in healthcare. 13 In 2010, the predecessor to NBHWC was formed by emerging industry leaders to develop national training and education standards and a national certification examination. 14 These accomplishments were supported by a collaboration with the National Board of Medical Examiners, laying the ground for the health and well-being coach on the healthcare team.
The new coaching profession aspires to fill a gap in healthcare and lifestyle medicine, in part revealed by transtheoretical model studies of the forces that govern readiness to change health behaviors. Most people lack the requisite levels of 2 forces—motivation and confidence—for starting and sustaining new health behaviors. 15 The coaching profession found a theoretical home in the transtheoretical model, and also self-determination theory (SDT). 16 SDT’s founders, Edward Deci and Richard Ryan, built SDT empirically beginning 4 decades ago, to deliver an evidence-based theory of human motivation and well-being. SDT is summarized as follows: 17
“People are active organisms, with evolved tendencies toward growing, mastering ambient challenges, and integrating new experiences into a coherent sense of self. These natural developmental tendencies do not operate automatically, but instead require ongoing social nutriments and supports.”
Coaching is designed to provide social nutriments (supporting autonomy, developing competence, through a trusting partnership) that help unleash the natural human tendency toward interest, growth, and mastery of self and one’s environment. SDT is considered to be the theoretical foundation of motivational interviewing (MI), 18 and is well integrated into health and well-being coaching. Although SDT and MI emerged separately in parallel, MI’s relational skills bring SDT into coaching practice through open inquiry, active listening, reflections, affirmation, and rolling with resistance (e.g., empathy and respect for the benefits gained by a patient from their engagement in unhealthy behaviors).
Applying the transtheoretical model, SDT, MI, and other domains together, the art and science of coaching delivers the social nutriments that people need to be open, curious, and autonomously motivated, and then to move in the direction of more competence and well-being. As people improve their health and well-being, along with their work and their lives, they integrate their challenges into continuous growth and more wholeness.
That all sounds straightforward, to unleash human potential and well-being through coaching. Yet, coaching conversations are anything but straightforward, easy, or predictable. The enthusiastic passion of lifestyle medicine practitioners meets a human wall of life stressors and challenges weighing down motivation and confidence. Chronic stress, 19 burnout, 19 anxiety, 20 depression, 20 loneliness, 21 cultural and socioeconomic inequities, 22 plus the collective trauma of a pandemic, 23 deplete the resources people need to get healthier. Low levels of readiness to change 15 are created by gaps in internal and external resources that depress confidence and motivation and stop behavior change in its tracks.
In the practice of lifestyle medicine by subject matter experts, motivation and confidence-building interventions based upon education and skills training are the norm. Effective, established interventions include the Ornish intensive lifestyle intervention, 24 the Teaching Kitchens Collaborative program, 25 mindfulness-based stress reduction, 26 and many others. However, when a patient has depleted resources and a low readiness to change, they are unable to benefit from these effective interventions.
Coaching Mindset is Ground Zero
Another starting point, prior to prescribing, educating, and behavioral training, is to shift our mindsets as lifestyle medicine practitioners. We meet a patient right where they are now, in contrast with jumping into an education and training program. Collectively, the field of lifestyle medicine benefits from this coaching mindset. 27
Our Mindsets are Ground Zero—Hold Space, Not Fill Space
Self-determination research is best known for identifying three primary psychological needs (Figure 1 left side), the absence of which lead to languishing, and the presence of which lead to flourishing. These core needs are autonomy, competence, and relatedness. 28 A coaching session has the purpose and initial focus of drawing out another’s autonomy, generating high quality, aka autonomous, motivation, 29 (what is important to you that good health enables? what matters to you most about your health? what do you want most to do?). Coaches help others invest their high quality motivation into a day-by-day focus on getting better, and developing competence and confidence (what do you want to get better at? what does being confident look like for you?).
Figure 1.
Core psychological needs of self-determination theory for coach and expert.
A ground zero mindset, then, is one where we hold space for motivation and then confidence to emerge rather than fill space with expert knowledge and guidance.
The challenge is that as helpers we are human, and our expert minds are full, informed by our own core needs of autonomy, competence, and relatedness (Figure 1 right side). Our own needs lead us to judge (asserting our own values and knowledge of what’s best), fix (giving advice and answers rather than enabling people to learn to find their own), and rescue (jumping in too quickly rather than giving people space to reflect and discover their own way). With the best of intentions, we fill space in conversations by inadvertently introducing our needs to judge, fix, and rescue, rather than hold space for others’ needs, desires, and ideas to be revealed.
Beyond our impulses to judge, fix, and rescue, there is more activity filling our minds and impairing access to the present moment. Lisa Feldman Barrett’s constructivist theory of emotions 30 posits that the brain is not automatically focused on directly experiencing the present reality (including other people) and then communicating that experience to our awareness. The brain focuses on monitoring our internal needs and resources, as well as external events, with the aim of predicting the external demands on our resources. The brain’s predictions are conveyed to our awareness through our emotions and thoughts. Our mental activity in any given moment, then, is not a direct response to the present experience of the needs, wants, and resources of the person we are helping, but rather the brain’s predictions of the impact on us of that reality. Clearly, we can’t hold space to help others if our minds are full of our self-oriented, usually well-intentioned, thoughts and emotions.
In mindfulness training, 31 you learn how to set aside the mind’s automatic activity, setting it down as though it was a pair of virtual reality glasses. You can then be present. You can directly experience others through your senses. Your senses receive the experience (holding space), rather than sending your thoughts and emotions (filling space). To bring yourself to ground zero—you open space in your mind so you can directly perceive the other and hold space for them to open up, get curious, and reflect on themselves and their situations.
Extending the ground zero metaphor, when we are in a ground zero mindset, creating space in our minds and holding the space in which others can roam around, we are also grounding others in a safe space. The electrical charge of our judgments and agendas is grounded. This makes others feel safe, allowing them to open up, get curious, and have new thoughts and ideas.
Tilling the Ground
Another way to think about the word “ground” is that others’ ground is made up of the layers of ground under their lives, including the many layers of childhood and adulthood experiences and education. The lower layers of ground can be thought of as the social determinants of health. 32 Others’ ground may not be well aerated, fertilized, watered, or getting enough social sunshine. They may not have had the social nutriments they needed in the past, or in the present.
The social nutriments of our lives produce social resources; those resources include psychological capital, defined by positive psychologists as Hope, Efficacy, Resilience, and Optimism, 4 evidence-based resources making up the HERO acronym. 33 These resources support the readiness to change mindsets and behaviors.
Like a farmer tilling the soil, through open questions and thoughtful reflections, coaches begin to till the top layer of the other’s ground, sensing what is just enough tilling and not too much. In this way, we become a positive social determinant of health, a social resource. Through our inquiries, exemplified in Table 1, we are aerating, watering, fertilizing, and energizing the others’ ground, by posing questions that cultivate the seeds of motivation, resources, and confidence.
Table 1.
Tilling the Ground with Inquiries on Motivation, Resources, and Confidence.
| Till the ground to grow seeds of motivation |
| What is important to you about your health now? |
| If you imagine yourself as being well, what do you see? |
| What do you want to do about your health? |
| What do you want to get better at? |
| What will happen if you are not healthy? |
| What would you be able to do if you were healthier? |
| Who could be a role model to inspire you? |
| Till the ground to grow seeds of resources |
| What is going well in your life? |
| What is going well in your health? |
| What are you looking forward to? |
| What are you hopeful about? |
| Who is helping you feel safe and stable? |
| What helps you be resilient when life throws you curve balls? |
| Who might be able to cheer you on, and support you well? |
| Till the ground to grow seeds of confidence |
| When were you at your best, your healthiest? |
| What conditions (internal, external) helped you to be healthy? |
| What strengths do you use with your friends/family/at work that you can use to get healthier? |
| What would your friends say are your strengths? |
| What has worked before when you were learning a new skill? |
Generating Potential for Change
Once a patient’s ground is tilled just enough, and more resources are online, their urges to get better, move toward a desired future, and be more generative, are awakened. The potential in the moment arrives, potential for a small change in mindset that improves motivation and confidence, and supports new actions. This phase of a coaching session is a generative moment, also known as relational flow. 13 Patients are ready to generate new ideas, perspectives, insights, and possibilities, with the desire to get past where they feel unresolved or stuck. A coach’s ability to facilitate a generative process where a patient integrates new insights is important to sustaining a patient’s interest and engagement in a coaching program. 34
The Potential is Integration—The Ah-Hah Moment
In a generative moment, once more resources are online, a patient yearns to overcome something in the way—to resolve the unresolved, to settle the unsettled, to move from feeling the discomfort of being stuck to a more fluid, flow state. This process, described as integration by psychiatrist and integration expert Dan Siegel, 35 involves connecting to and integrating new ideas, thoughts, and perspectives. Uncomfortable emotional and mental states are like signals, unintegrated states available for integration—for connection to new thoughts, ideas, and perspectives.
A moment of integration can also be described as a moment of insight, an ah-hah experience, as though neurons just made new connections. Insight is defined as “a sudden understanding that solves a problem or reinterprets a situation, but, due to its immediacy, seems to be disconnected from the immediately preceding thought.” 36
Interestingly, in an MRI study comparing EEG activity of non-directive coaching (as described in this article) and directive coaching (instructing and advising), non-directive coaching showed EEG activity consistent with higher generation of insights than directive coaching. 37
Examples of integration, and insight generation, in the context of lifestyle medicine include:
• Unresolved (I don’t have time to exercise) to resolved (When I exercise, I might feel better and get more done)
• Unresolved (I don’t like cooking veggies) to resolved (When I consider the variety of textures and colors, cooking veggies seems interesting)
• Unresolved (I don’t think my doctor’s treatment plan is possible right now) to resolved (I can start with a part of the treatment plan that feels doable)
Dan Siegel notes in his book Mindsight, 38 which explores the phenomenon of integration: “I’ve come to believe that integration is the key mechanism beneath the presence of mental well-being.”
At its best, the lived experience of continuous integration is inviting: “We sense the familiar but are not trapped by it. We live at the threshold of the unknown and have the courage to move into new and uncharted waters. This is living a life as it unfolds, moment by moment, in a river of flow in the middle between two banks – one of rigidity (wanting to control) and one of chaos (feeling out of control).”
A generative moment in coaching is a healthy process of integration in action. Being in touch with the uncomfortable state of feeling stuck, and through a non-linear and generative coaching conversation, inviting and taking in new and varied perspectives, a moment of integration arrives. Something that was unresolved is resolved in the moment, or sometime later after the potential for resolution following the conversation comes online.
Self-determination theory views integration as the healthy and natural process of turning life experiences into well-being. Recall the quote cited earlier in this article: “People are active organisms… integrating new experiences into a coherent sense of self.” Integration starts with awareness—paying attention to the emotional experience (I don’t like the plan my doctor proposed. I find exercise boring.), exploring it without judgment or distortion. 39 Then an opening up of different vantage points follows which generates opportunities for integration and insight generation (If your daughter had this concern, what would be your advice? What would your higher self say? If your body had a voice, what would it say? How would your future self-think about this issue?).
Conclusion: Till the Ground, Generate Potential, Enable Integration
We played around with the ground zero metaphor throughout this article, to frame a number of considerations for the lifestyle medicine mindset:
1. Ground zero is a coaching mindset—meeting patients where they are, focused on improving motivation and confidence before jumping into education, skills training, and behavioral practices.
2. A ground zero mindset is creating and holding space, not filling space. We create space in our minds by setting aside all of our mental activity, including our own impulses to judge, fix, and rescue.
3. Tilling the ground is about inviting more motivation, resources, and confidence in the moment, which bring, metaphorically, more air, water, nutrients, and sunshine to a patient’s mindset.
4. Generating potential for mindset change is made possible when a patient’s ground is adequately tilled, so that the motivational urges arrive to move forward and tackle challenges.
5. A higher purpose of a coaching conversation is to create the conditions for insight generation, or integration of something that a patient wants to get past, or to resolve, in order to increase motivation or confidence in changing behavior.
6. The best coaching conversations now, and more healthcare conversations in the future, enable a patient to experience integration and insight generation—connect an unsettled, unresolved, stuck mental and emotional state to a range of new ideas, perspectives, and possibilities until an ah-hah experience emerges.
A ground zero mindset is an important opportunity for a lifestyle medicine conversation. It is a coaching mindset with the higher purpose, in support of behavior change, of healthy integration of the lived experiences, integrating the ups and downs on the journey toward good health through lifestyle medicine. There are opportunities in each conversation to till the ground—generate potential—and enable integration.
The last ah-hah in this article is that the integration process is what brings us to mastery of a coaching mindset over time, being able to hold a generative space for another’s experience of integration. We till our own ground, generate our own potential, and enable our own insights and integration of what gets in our coaching way.
We as lifestyle medicine practitioners are ground zero, modeling integration on the path to mindset and behavior change for the people we serve.
Footnotes
Authors’ Note: This topic was first presented at the Lifestyle Medicine Conference, Orlando, November 16, 2022.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.
ORCID iD
Margaret Moore https://orcid.org/0000-0002-2801-2287
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