A Coaching Model Created by Alexia Papageorgiou
(Health Career Coach, CYPRUS)
I have been working as an academic in clinical communication in medical schools in the UK and currently in Cyprus for the last twenty years. My background is in Psychology, Health Psychology and Psychiatry and I decided to train as a coach in order to allow myself professional flexibility in the years to come but most importantly because the philosophy behind coaching agrees with my principles and values as an individual and a professional.
I have worked with health care organisations and health care professionals throughout my career and before entering academia, I worked with users of psychiatric services in the community and psychiatric hospitals.
During my professional career, I embarked on a number of psychotherapy training, starting with group psychodynamic training straight after my first degree, Cognitive Analytic Psychotherapy training during my PhD in Psychiatry and Motivational Interviewing Training during my first academic job. However, I realised that working with just one psychotherapeutic approach was not for me. I am an eclectic person and I like to learn and adjust theories and skills to my personality. In coaching, I found exactly what I need as a health care professional. Through my ICA training, I feel, I got the freedom and flexibility to amalgamate my learning and experience and mould it to my own personal style.
Most of my clients but also people at work and at home/social life are pre-occupied with changing and or adopting one or more behaviours in relation to identity issues. So empowering people to change behaviours and how to maintain change has been a large part of who I am as a person and a health care professional.
My coaching model, Visualise your Identity and Live your Vision is based on four psychological approaches:
- Identity theory (PRIME)
- Motivational Interviewing (MI)
- Neuro-Linguistic Programming (NLP)
- Acceptance and Commitment Therapy (ACT)
In the following pages, I will give a short description of each of the above and then try to convey to my readers how I use these approaches in my coaching. I will try to achieve the latter using a case example and base it on some ICF competencies.
Part A: Overview of Four Psychological Approaches
1. Identity Theory (Prime)
Professor Robert West at the Health Behaviour Research Centre, Department of Epidemiology and Public Health, University College London, has developed an Identity Theory called PRIME. PRIME stands for Plans (P), Responses (R), Impulses (I), Motives (M), and Evaluations (E). According to the theory, our behaviour is so much more than our reasons for performing the behaviour. “It is wanted and needs at each moment that drives our behaviour. Our intentions and beliefs about what is good or bad only influence our actions if they create sufficiently strong wants and needs at the relevant moment. Our image about ourselves and how we feel about that, our identity, is a very strong source of wants and needs which can be enough to overcome wants and needs that arise from our biological drives such as hunger.”
According to Prof West, our identity comprises of:
- Labels (e.g. non-smoker, vegetarian)
- Attributes (e.g. health-conscious)
- Rules (e.g. I do not smoke)
“A strong, coherent, deeply entrenched identity that places clear boundaries around a category of behaviour and which anticipates potential challenges will provide strong stability to that behaviour and yield a powerful predictive measure. Fostering such an identity around a new behaviour pattern is a potentially important target for behaviour change interventions. Self-consciously stopping doing something typically means:
- Forming a rule (plan) not to do it, or
- Forming a rule (plan) that one will ‘try’ not to do it
- Applying that rule in relevant situations which generates a want or need not to do it which adds to those that led to the rule.” (http://www.primetheory.com/summary-prime-motivation.php)
2. Motivational Interviewing (MI)
Motivational Interviewing (MI) was discovered by Stephen Rollnick in 1983 who worked with William Miller to produce the first book on its principles in 1991. MI is a counselling style that guides people to become aware of the nature of their behaviour and the effect on their personal values, life goals and their social environment. It guides people to elicit their own good motivations for making behaviour changes and empowers them to create alternatives in their social environment which will help them to change and maintain change. (Miller & Rollnick 2012)
MI can be delivered as a one-off or more sessions depending on the target behaviour.
According to Miller & Rollnick (2012) the bullet points below encapsulate the spirit of MI:
- Create a collaborative approach between coach and client. The therapeutic relationship is more like a partnership or companionship than expert/recipient roles.
- Listen with empathy.
- Avoid the “righting reflex”. “People who enter helping professions often have a powerful desire to set things right, to heal, to prevent harm and promote well-being. When seeing someone headed down the wrong path, they will usually want to get out in front of the person and say, ‘Stop! Turn back! There is a better way!’ (Rollnick et al 2008, p. 7)
- Be evocative, motivation to change is elicited from the client, and not imposed from the coach. The coach guides the client to connect behaviour change with what he/she cares about, their own values and concerns. Direct persuasion is not an effective method for resolving ambivalence.
- Honour client’s autonomy. “MI requires a certain degree of detachment from outcomes-not an absence of caring, but rather an acceptance that people can and do make choices about their course of their lives.” (Rollnick et al 2008, p. 7) Empower the client. It is the client's task, not the coach's, to articulate and resolve ambivalence.
- Consider readiness to change a fluctuating product of interpersonal interaction and not a client trait.
The motivational interviewing skills that I use most often to empower clients to achieve awareness are (Rollnick et al 2008):
- Eliciting the client’s motivation for change (e.g. On a scale from 0-10 where 0 is not at all important and 10 it is very important, how important is it for you to get x,y,z?”
- Eliciting the client’s confidence in changing (e.g. On a scale from 0-10 where 0 is not at all confident and 10 is very confident, how confident are you to do x,y,z?”
- Exploring client’s ambivalence and listening for change talk.
- Rolling with resistance.
3. Neuro-Linguistic Programming (NLP)
NLP was developed by linguist John Grinder and Richard Bandler with a background in mathematics and gestalt therapy.
“NLP is a pragmatic school of thought-an ‘epistemology’-that addresses the many levels involved in being human. NLP is a multi-dimensional process that involves the development of behavioural competence and flexibility, but also involves strategic thinking and an understanding of the mental and cognitive processes behind behaviour. NLP provides tools and skills for the development of states of individual excellence, but it also establishes a system of empowering beliefs and presuppositions about what human beings are, what communication is and what the process of change is all about. At another level, NLP is about self-discovery, exploring identity and mission. It also provides a framework for understanding and relating to the ‘spiritual’ part of human experience that reaches beyond us as individuals to our family, community and global systems. NLP is not only about competence and excellence, but it is also about wisdom and vision.”
The NLP skill I use most often in my coaching is visualization which “helps clients obtain a clearer picture of what they want, rehearse or imagine their success, and create a self-confident frame of mind….. positive visualizations create the right physiological and neural conditions to boost clients’ success and achievement.”
4. Acceptance & Commitment Therapy (ACT)
ACT was developed by Dr Russ Harris: Medical Practitioner, Psychotherapist and Executive Coach. “The aim of ACT is to maximise human potential for a rich, full and meaningful life. ACT (which is pronounced as the word ‘act’, not as the initials) does this by:
a) teaching you psychological skills to deal with your painful thoughts and feelings effectively – in such a way that they have much less impact and influence over you (these are known as mindfulness skills).
b) helping you to clarify what is truly important and meaningful to you – i.e. your values – then use that knowledge to guide, inspire and motivate you to change your life for the better.
Accept what is out of your personal control, and commit to action that improves and enriches your life.”
The skills I use most often from this approach are the following (Harris 2016, p.7):
- Cognitive defusion which refers to training clients to “perceive thoughts, images, memories and other cognitions as what they are-nothing more than bits of language, words and pictures-as opposed to what they can appear to be-threatening events, rules that must be obeyed, objective truths and facts.”
- Acceptance which refers to “making room for unpleasant feelings, sensations, urges, and other private experiences, allowing them to come and go without struggling with them, running from them, or giving them undue attention.”
- Contact with the present moment which refers to “bringing full awareness to your here-and-now experience, with openness, interest, and receptiveness; focusing on and engaging fully in whatever you are doing.”
- Committed action which refers to “setting goals, guided by your values, and taking effective action to achieve them.”
Part B: Coaching Application
Mrs Sally Thompson, a 42-year-old lady, came to me following a visit to her family doctor for her annual health check. Her health check showed elevated blood pressure and on a further medical investigation, she was told that she had a thickened left ventricle and elevated blood lipids. Her doctor suggested she needed to go on anti-hypertensive medication, a lipid-lowering drug and urged her to seek dietary and lifestyle modification advice in order to lose weight and stop smoking. Sally worked as a community psychiatric nurse, was married to David a DIY store manager and had three children aged 10, 12 and 15.
The client’s identity and personal details have been changed in order to protect her anonymity.
Establishing the Coaching Agreement, using NLP and PRIME theory
Before our first meeting, I sent via email to Sally my “starter pack” which explained what coaching is and what coaching is not, who I am and how I work, what my code of ethics and standards is, a questionnaire to complete with her personal information and a pre-and-post coaching form.
During our first meeting Sally’s agenda was:
- I need to define who I am and what I want and improve my relationships with my family and to free myself from my excess weight, smoking and other unhealthy habits.
- Be well – be happy and make others around me happy by becoming a good role-model for my children and my patients.
- Set priorities right.
- Live life to the maximum of my abilities as well as offer the best to my marriage, children, family and friends and my patients.
We discussed a narrowing down of her agenda to something she wanted to focus on our first session. She thought that everything was important and did not know where to start but she wished for more clarity by the end of the session. To facilitate progress on her agenda, I asked her the following question: “If you had a magic wand and could change yourself in every aspect what would your new self look like?” Sally’s response provided clear “labels=slim, non-smoker, healthy”, “attributes=health conscious and a good role model” and “rules such as I resist the urge to smoke and drink in order to unwind and/or cope with stress”. When Sally finished I asked her how she felt visualising her new identity. She said she felt energised but also scared that she may not be able to get her dream true.
Using MI to establish the client’s readiness for change and motivation
I thanked Sally for sharing with me her vision and I acknowledged that the thought of embarking on such a big change as the one she visualised was a challenging task. After a few minutes of silence, I asked her what she was thinking and she said: “I am thinking of this wonderful new me but I dread the road to getting there.” At that point, I asked her (eliciting her motivation to change) “On a scale from 0-10 (where 0 is not at all important and 10 is very important) how important is it for you to get this new self?” Sally’s response was 7/10. Did I ask her why 7 and not 5?
Sally: “I am only 42 years old and my health is already suffering. What will happen to my children if I don’t change and my health becomes worse? What kind of role model am I for them? How can I tell them that smoking is bad for them when they see me smoke? It is my patients too. Most of them smoke and they discuss with me their desire to stop but how can I help them when I haven’t even tried stopping? I have a lovely husband who loves me and accepts me as I am but I am not happy with my body any longer. It is as if I am wearing ten coats on top of each other. I have to change, I have had this feeling for some time now but the last visit to the doctor’s office was my weak up call. I can’t bury my head in the sand any longer.”
Coach: “I can hear your desire to change and I can also hear the strong driving forces behind this desire: staying healthy for your children and becoming a good role model for them and your patients, taking off the multiple layers of “coats” you are carrying with you.”
Sally: “Yes this is right.”
Coach: “So what do you make of all of this now?”
Sally: “I feel I am ready and excited to embark on a new journey but where do I start from?”
Coach: “Would it help you if you thought of a journey that you embarked before?”
Sally brainstormed about the last holiday they had as a family. Her positive experience provided the platform for planning and goal setting. She realised she had to pick a destination for her coaching journey, think of the means to get there, anticipate possible obstacles and also think of support mechanisms. By the end of our first session, she decided to focus on stopping smoking as her main goal and she wished to email me a table with the advantages and disadvantages of smoking and quitting smoking as her way forward (exploring ambivalence). Sally said she gained clarity and felt empowered to tackle her health issues before leaving our first session.
Using NLP and Acceptance and Commitment Therapy (ACT)
After a couple of sessions, during which we explored her ambivalence and her confidence, Sally decided that it was time to throw in the bin her pack of cigarettes and “go cold turkey”. During our coaching sessions, Sally was able to visualise and accept or make room for unpleasant feelings, sensations urge and other private experiences in relation to quitting smoking. She worked hard to operate in the here-and-now to establish firm identity boundaries as a non-smoker. She was able to implement her learning outside coaching and to protect her new identity boundaries by avoiding smoking areas during her breaks, socialising with non-smokers at work and engaging in healthier activities such as going for a walk around the block for a break. The money she saved from her smoking went into a special money box and became a further incentive for strengthening her identity.
Sally explained that staying in contact with the present moment and becoming a passive observer of very strong unpleasant feelings gave her a power she was not familiar with. She also said that by not fighting and not resisting strong unpleasant feelings made them lose their power and strength over her.
By the end of our work together (18 sessions over a year), Sally was able to align her values and behaviours with her new identity and this alignment and progress made her more confident and committed to living her vision.
My coaching model, Visualise your Identity and Live your Vision represents a large, valuable, and flexible toolbox with many psychological approaches in it. So far I have been using most often the four below:
- Identity theory (PRIME)
- Motivational Interviewing (MI)
- Neuro-Linguistic Programming (NLP)
- Acceptance and Commitment Therapy (ACT)
However, in my mind, the more I learn and practice as an academic, as a coach and as a human being the more tools I can get in my toolbox. In addition, I feel flexible to clean the toolbox from things that don’t serve me any more and make space for new approaches and new tools.