The relationship between the health coach and the patient is critical for a successful collaboration in planning and achieving a behaviour change.40 Behavioural change interventions require trust, thoughtful and non-judgmental communication that respects the patient’s autonomy, and a process that is appropriate to their knowledge, motivation and capacity.
The Therapeutic Alliance
The skills employed in health coaching are congruent with those of physiotherapists as described in the therapeutic alliance in physiotherapy.41 Both stress the importance of setting collaborative goals, setting tasks aligned with those goals, and the importance of an interpersonal, trusting bond between the patient and the health-care professional.42 Research has identified that being present, receptive, committed, and genuine were necessary conditions for a positive physiotherapy therapeutic relationship.43 These conditions reinforce actions that establish connections with the patient, through acknowledging the patient as an patient by meeting them as a partner, validating their experiences, and individualizing treatment to the needs of the patient.44
Health coaches consistently demonstrate empathy and a respectful manner that builds a non-judgmental, collaborative relationship. They show respect for the patient and their unique perspective, feelings and values and maintain an attitude of acceptance, but not necessarily approval or agreement. Using verbal and non-verbal messaging to communicate that they understand the patient’s situation will reinforce collaboration and concordance in setting goals.
Thoughtful communication is an essential element in health coaching. It can facilitate and support the patient’s consideration of, and decision to make a change in health behaviour. The health coach seeks to learn the patients’ knowledge or understanding of their condition, the goals they would like to achieve, and the factors that will affect achieving them (both positive and negative). The health coach then provides information that is targeted to the patient’s understanding, needs and personal situation.
Communication in health coaching strategies includes:
- Asking, not telling: Open ended questions communicate that the coach values the autonomy of patients as a partner and encourages a discussion of their concerns about their condition, what they would like to change, and when and how this might happen. Examples include, “What do you see as your biggest challenge?”, “What have you tried in the past?,“ “Would you like to know more about....” or “How do you think you could....”
This also helps the coach learn about his/her patients’ level of health literacy – what they understand about their condition. The coach can then target any evidence-based information to provide regarding their level of understanding and needs.
- Active listening: The health coach is aware of his/her own body language and non-verbal cues that lets patients know they have the coach’s attention. (e.g., making eye contact, mirroring postures, nodding to acknowledge comments).
Being open-minded and non-judgmental. The health coach avoids making negative comments, criticism and/or correcting the patient, seeking only to clarify the patient’s perspective (e.g., “It sounds like you have...” , “Am I correct in thinking that...” rather than “You shouldn’t...” or “you need to...)
- Reflective listening/responses: Repeating, restating or clarifying the key points in what the patients have said communicates to the patients that the health coach has heard them, values their concerns and wants to understand their point of view. It may also help the patient gain an additional perspective to reflect on as they consider making a change in behaviour.
- Maintaining a respectful manner: Communicating a positive regard for the autonomy of patients will allow a discussion of their situation without overwhelming them with information. For example, when patients identify a specific concern, the health coach first explores what the patients know already, and then inquires if they are interested in knowing more. By responding to the specific question or issue, rather than providing a global explanation of the whole topic, patients are enabled to review their situation and make decisions based on their understanding and new learning.
As in all aspects of care, thoughtful communication improves compliance and is an important factor in improved outcomes.45
Motivational Interviewing (MI) is one methodology used effectively in health coaching. MI is a “collaborative, person-centred form of guiding to elicit and strengthen motivation for change,”46 and like all other professional skills, requires training and practice. Within health coaching, MI is used to assess the readiness of patients for change, build on their ability or capacity to make a change, and to set realistic goals.
MI focuses on “evoking and strengthening” the client’s own verbalized motivations for change.47 Its guiding principle is that the patient articulates the arguments for change, not the professional.48 Arguments, or reasons, for change are classified as “change talk.” Conversely, reasons for maintaining the status quo are classified as “sustain talk.” The focus of MI is to explore those reasons, resolve the ambivalence to change and guide the patient as they shift to “change talk.”49
MI integrates common communication strategies under the following set of principles:
- It requires the physiotherapist to adopt an empathic style that is accepting and a belief that ambivalence about change is normal.
- Using MI techniques helps the patient recognize discrepancies between their stated goals and their current situation, avoids arguments (“rolls with resistance”) and supports self-efficacy. “Rolling with resistance” acknowledges any negative comments and reframes them by, for example, restating them as a neutral reflection, or by providing information that may shift the patient’s perspective.
- It requires the physiotherapist to remain focused on the goals and values of patients – it is not a series of questions intended to convince them to change behaviour, or to pressure them into making a change that the coach has identified as important.50
Although training in MI is recommended, Rollnick et al provided family physicians an introduction to the core strategies,51 and recommended the use of:
- The guiding style
- Open ended questions that ask the patient to consider how and why he or she might change
- Using reflection or other means to show empathy and encourage discussion
- Asking permission to provide evidence-based information; ask what more information might mean to them (e.g., “would you like to know more about?”, i.e., effects of physical inactivity, weight gain or chronic condition diagnosis, ..or “what do you think that (information) means for you?”)
- Building on patients’ strengths, such as:
- Setting the agenda by asking them to select the issue or problem that is their priority.
- Assessing their ambivalence to change – what are the pros and cons? Is change a possibility?
- Determining what the importance of making a change is. If its importance is not high, supply information for further review, recognizing their autonomy in decision making.
- Exchanging information– elicit what the patient understands, provide information on potential result of not changing (both positive and negative), elicit their understanding of any personal implications of making a change, as well as not making the change.
- Responding to patients’ language – as in active listening.
- Use open-ended questions. When patients engage in “change talk,” which suggests they are thinking of change (e.g., “I should...” “I want to...“ or “I know it would be better if I ...”) the coach’s response might be to say “You feel that…” or “How do you think you might...” that encourages more discussion about change. When they use “sustain talk,” indicating preference for the status quo ( e.g., “I enjoy...” or “I have never succeeded in...”) the coach attempts to move the conversation towards change, using questions such as “What do you see as drawbacks to...”, “What would happen if...” or “How might things be different if...”
MI requires training to learn the skill and achieve competency to practice. The Resources Section provides links to opportunities for training and online resources in MI, including a webinar on MI by D. Gross, PT, PhD and Joanne Park, OT, PhD hosted by Physiotherapy Alberta College + Association.
Behaviour Change Techniques
Behaviour change interventions include all the components of a health coaching strategy. Behaviour Change Techniques (BCTs) are the active and measurable components.52 These techniques offer a broad range of tools a health coach can employ to facilitate health behaviour change at any stage in the process of behaviour change. Similar to MI, BCTs can prompt reflection, identify barriers or obstacles to change, build self-efficacy and help implement or maintain a behaviour change. For example, an active learning strategy may use problem solving (a BCT) in conjunction with other BCTs such as goal setting, self-monitoring, behavioral prompts, cognitive coaching, and reinforcement to achieve a goal.
BCTs may be behavioural, cognitive or motivational and can be implemented throughout the behavioural change process. Recent research suggests that combining BCTs that facilitate self-regulation, defined as the physical skills and function, or the “how to,” with communication that addresses the underlying motivation, the “why,” supports maintaining a new behaviour over time.53 For example, an older adult may cite maintaining independence as their primary goal because they enjoy travel, while a younger person may focus more on resuming a particular sport or activity, because he or she is looking forward to a tournament. For the former, BCTs may be targeted to prompting graded exercise and identifying barriers, while for the latter, pacing and visualization may be most effective.
“Active” or behavioural BCTs, such as pacing and self-regulation, which encourage symptom self-management, have been shown to be more effective than “passive” or cognitive techniques, such as education and advice, for maintaining physical activity in people with OA.54 Similarly, BCTs such as graded activity, self-monitoring, recording activity outcomes, or planning and implementing environmental changes are effective for increasing physical activity and for healthy eating.55
Appendix 1 is the PT-BCT Checklist, developed in 2014 by Harman, MacRae, Vallis and Barrett,56 and is used with permission. The checklist includes BCTs specific to physiotherapy practice and were selected from Abraham and Michie’s taxonomy of BCTs.57 The BCTs and their descriptions in the checklist relate to chronic MSD disorders, but are applicable to other areas of physiotherapy practice.