Found this great article on compliance with clients! My course students and fellow health and wellness professionals can benefit from the wisdoms of these folks.
The Compliance Solution
Research shows that breaking down tasks supports the brain and makes goals easier to reach.
Tough clients. Every health and fitness professional’s got them. You know, the ones who make you gnash your teeth, bite your tongue and think, “What is wrong with you? Why can’t you follow simple instructions or do what’s good for you?” Don’t take it personally. Pharmaceutical companies and physicians are gnashing their teeth as well. Too many medical patients are not taking their pills. When prescribed life-saving medications for cancer, heart disease and diabetes, patients take them a shockingly low 55% of the time, according to a World Health Organization (WHO) estimate (WHO 2003).
If almost half of people can’t spare 10 seconds to pop a pill, how in heaven’s name can we expect them to exercise and to eat a healthy diet? Again, as fitness and nutrition professionals, we wonder, “What is wrong with these clients? Why are people so . . . illogical?” The answer is illuminating.
Most of us assume that human beings base decisions on the rational deliberations of the logical left brain—the “inner grownup.” However, behavior research—including neurological imaging data—suggests otherwise. What really drives most of our decision-making (whether we’re willing to admit it or not) is our emotional, empathetic, image-oriented right brain (Colozino 2010; Greenberg 2010; Johnson 2004).
In addition, clients’ puzzlingly contradictory behavior reflects competing life priorities and brain circuits. People are usually unaware of these internal conflicts, so it’s hard for clients to explain why they sign up for a gym membership and then never show up, or vow to eat better at 9:00 am but end up in the ice cream at 9:00 pm on the same day (Colozino 2010; Johnson 2004).
In this article, we’ll explore what’s going on in clients’ brains and lives, and how you as the coach or trainer can help get (and keep) people on the right track. Be warned: This may require you to examine your own internal contradictions—and possibly do things a little differently.
The Elephant in Your Brain
We all like to assume that we’re rational, logical beings who make well-considered decisions based on a careful review of all the available evidence. But in the groundbreaking book Switch (Crown 2010), authors and brothers Chip and Dan Heath liken the relationship of the right brain and the left brain to that of an elephant and the person riding it. The powerful, potentially unreliable elephant is the emotional, intuitive right brain. The rider is the rational left brain. The rider might be in charge for a while, but the elephant will always win in the end, especially if rider and elephant are at odds and the rider tires from constant responsibility, decision-making and elephant steering.
There are many reasons why the elephant may become unruly. First, brain circuits dedicated to keeping us logical and reasonable (circuits such as the orbital-medial prefrontal cortex, or the OMPFC) were late developments in the evolutionary game. Our “smart human” brain components evolved much later than our “reptilian” components (which control things like breathing, heart rate, fluid balance, etc.); our “early mammalian” components (which control things like mating and social behavior); and our sensory and motor components (which help us see, hear, taste, smell, stay upright and play tennis) (Colozino 2010; Johnson 2004). The “smart human” brain components floating around behind our eyes don’t have neurological primacy. In other words, they’re not our evolutionary “default setting” and thus don’t guide our bodies and our behavior as much as we might prefer (Greenberg 2010).
For the most part, our physical sensations, feedback loops and emotions actually drive the bus. Whether we’re aware of it or not, most of the time the more primal brain circuits are in charge of our decisions (Ogden, Minton & Pain 2006). Indeed, the “smart human” brain contributes much less than we think. Don’t believe it? Check your heart rate and palms next time you feel road rage. That spike in heart rate and the sweaty palms are your sympathetic nervous system–dominant defense mechanism kicking in to keep you safe from the “threat” of that driver who cut you off while talking on his cell phone.
Second, the “reptilian” and “early mammalian” brain parts are dedicated to our survival (Cozolino 2010; Greenberg 2010). They want to feed us, keep us happy, keep us safe and make us feel as good as possible. Yet “dieting” or embarking on a new fitness plan in the 21st century means purposely enduring discomfort and restricting activities and foods that soothe us (or give us a “high”). It also means adding more demands or stimulation to an already busy schedule.
If you think about it, why would any client ever eat less and go to a gym with bright lights, loud music and unfamiliar equipment, in order to expend excess energy? To the primal brain, these things are a threat. Threats require defensive action—such as running away or playing dead. In the context of a wellness program, that means bailing on a gym membership, “flaking out” on a meal plan, being lazy or “forgetting” to plan a healthy dinner (Ogden, Minton & Pain 2006). Purposely enduring restriction, social awkwardness or discomfort goes against everything our brains evolved to do. So trying to persuade a client to do this is like trying to run new software on a very old computer.
Finally, some evidence suggests that “willpower”—or the conscious “control” of unwanted impulses—may actually use up much of the brain’s fuel resources. Functional MRI studies that have looked at glucose utilization in the brain seem to show that self-governance is energetically costly (Cozolino 2010). The ability to discipline ourselves is a bank account that gets depleted quite quickly, especially if we’re making constant withdrawals without also making willpower-boosting deposits (such as enjoyment).
You don’t need to be a neuroscientist to get all of this. Just remember three things:
1. In neurological terms, we’re wired for safety, comfort, energy conservation and survival.
2. For most clients, working out and changing eating habits contravene those primal goals.
3. When humans perceive a threat (real or imagined), their defense mechanisms kick in. When that happens, you won’t get anywhere with them, especially if you push harder.
Shaping the Path
According to the Heath brothers, there’s one additional and critical part of the equation—the path the elephant treads. This is the environment: circumstances and structures that shape our choices, often without our conscious awareness.
According to the elephant rider analogy, when we complain that clients “don’t listen” or “can’t stick to a new program,” what we’re bemoaning is the loss of rational (or rider) control. In our clients, as in all humans, the left brain is the elephant rider. It is trying to stay on track with a good nutrition or fitness program, but it is operating in an obesogenic (tending to cause obesity), scary, emotionally taxing world.
In fact, entire industries are now based on tweaking our brain circuits. Fast-food companies poke at our visual cortex with omnipresent flashy ads, bright colors on packages and delectable images. Food manufacturers purposely create foods that light up our brain’s reward pathways and make our tongues and noses do a happy dance. This food also gives us—in abundance—what would have been scarce and valuable a million years ago: salt, sugar and fat. Why on earth would our primal brain trade deep-dish pizza for rice cakes? “Eat it now! Famine could strike any minute! Maybe have a nap afterward and save energy!” says our reptile voice.
In the meantime, our personal stress has increased. According to WHO (2001), depression and anxiety are now the top mental illnesses in industrialized countries. This isn’t because we’re naturally neurotic, but because the world is so stimulating, demanding and frazzling that our Stone Age physiology and neurology can’t cope. Full of fast food, work and family pressures, car commutes, sedentary labor and few opportunities for natural movement, the environment we live in is deeply frightening to the emotional elephant.
Combine the elephant’s natural fear and avoidance responses with an environment that presents us every day with hundreds of decisions and lots of ways to get off track, and you can understand why clients are mentally exhausted and dipping into the doughnuts.
The Critic Versus “Flow”
Appealing too much to our clients’ left brains may sometimes be counterproductive. In his well-known book Flow (HarperCollins 2008), researcher Mihály Csíkszentmihályi notes that when we are “in the zone”—performing effortlessly and joyfully, unaware of time and unimpeded by obstacles—we’re actually using our “nonrational” brain. We’re effectively synthesizing the various parts of our brain. Sports psychologist Timothy Gallwey, famous for his Inner Game series of books (Random House 2001; 2009), concurs: You can’t think your way into “flow” or into “the zone.”
In fact, too much left brain action creates what Gallwey calls Self 1: a critical, nattering know-it-all bean counter whose exclusive job is to point out errors and dissect our performance to death. When we are in Self 1, we can become paralyzed by analysis. Sound familiar? This is the client who likes highly complicated fitness programs or meal plans (designed by a registered dietitian), but who never follows them because she’s overwhelmed by getting the details just right. Although it seems logical, overemphasis on Self 1 and the left brain actually inhibits learning and neuroplasticity. In other words, when clients feel anxious and self-critical about performing, there’s never going to be lasting change.
Conversely, what Gallwey calls Self 2 is the self that “flows,” calls up the best aspects of our whole brain and puts them to work in a harmonious whole.
What inspires Self 2 and inhibits Self 1? Bringing awareness to simple tasks and focusing on one basic thing at a time; emphasizing behaviors rather than goals or outcomes; feeling good about meaningful accomplishments; and shaping the environment so that clients can’t or don’t have to overthink. Self 2 can just do.
Strategies for the Whole Brain and the Environment
So how can you, as a coach or trainer, intervene? According to the Heath brothers, you can support the rider’s rational brain in three ways:
Follow the bright spots. The rational brain is easily rallied by the stories and processes of previous successes. Therefore, in the case of nutrition or fitness coaching, highlighting previous clients’ successes through photos and stories isn’t just good marketing; it also helps future clients succeed.
Script the critical moves. Without clear, explicit, step-by-step instructions, the rider spins off into a world of “What if?” analysis. Get around this tendency by providing crystal-clear, easily measured habits for the client to adopt.
For example, instead of simply asking a client to eat more veggies, keep the rider focused by specifying one habit; for example, “Add one serving of your favorite vegetable each day for the next week.”
Point to the destination. The rider needs to know where he or she is going. Therefore, point often to the ultimate destination (a leaner body, a smaller pants size, the experience of being less winded when climbing stairs)—and let the rider know what it’s like there. For instance, draw from testimonials of clients who have taken a similar path, and reinforce the positive outcome of sticking with the program. Introduce your beginners to your experienced clients so they can share their experiences with those starting out.
Next, you can guide the “right brain” elephant in three ways:
Find the feeling. Help clients find joy in healthy behaviors while working through fears that may make them “rear up” and avoid those activities. Finding the feeling often begins with identifying clients’ key motivators (positive or negative) and speaking to them. It can also involve speaking to Self 2 by helping clients tap into what makes them feel “flow.” One way to do this is to spend more time finding workouts and nutrition habits that clients feel excited about and confident in—and doing more of those versus the ones they may dread.
Shrink the change. The elephant is easily spooked by big obstacles, and the critical Self 1 will quickly kick in to explain all the reasons why this new project of eating well and exercising can’t work. However, very small, practical, daily actions and habits are easily absorbed. Most often, smaller is better. Just be sure the habits are directed at the client’s biggest limiting factor. For example, if a client consumes alcohol daily, don’t ask him to stop drinking; instead, shrink the change by suggesting he avoid alcohol 2 days per week. Over time, based on his confidence, you can increase the number of days. However, in the beginning, start small.
Grow the client. In most change situations, clients feel small in the face of change. This inspires the fear response, which shuts down change. Help each client make change feel small (shrink the change), while helping the client feel “large” and confident (grow the client). As we’ll discuss later in the article, the best way to do this is to present habits that a client feels 90% or 100% confident he or she can do. When clients develop a habit they’re very confident they can do, they win another victory with each passing week. Challenges feel smaller, and clients feel bigger.
Last, you can shape the path in three ways:
Improve the environment. Our environment determines success or failure, so we must help our clients improve their environment in order to succeed. Getting snack foods off the table and replacing them with freshly cut veggies is one example.
Build habits. Once a client’s behavior becomes automatic, it no longer taxes the individual’s willpower. Healthy “action triggers” support habit building. For example, if a client starts drinking 500 milliliters of water (action) after brushing her teeth (trigger), the behavior can quite easily become automatic because the trigger is there.
Rally the herd. No one succeeds alone, so it’s important to create “support circles.” Introduce clients to each other, schedule fitness- and nutrition-oriented social meetings, and help clients build a “health-promoting network.” Elephants are social animals, after all!
One Habit at a Time
Taken together, the strategies above may seem overwhelming. That’s because trying to do all nine of them at once is too much! We may believe that humans are good multitaskers, but most folks can focus on and properly do only one thing at a time (Babauta 2009). Too many demands at once generate stress. Stress shuts down learning, growth and change (Cozolino 2010; Csíkszentmihályi 2008; Dweck 2006; Gallwey 2001; Gallwey, Horton & Hanzelik 2009; Johnson 2004; Sapolsky 2004; Whitmore 2009). If you want to improve as a coach and a personal trainer, do less. Adopt only one new coaching action for a month or so. Add another action only after the previous step has been mastered. Your goal for each client should be twofold:
1. Lead the client progressively toward the desired change (Whitmore 2009).
2. Identify the “vital step” or “critical variable” that—although small—will help the client work through obstacles and yield the greatest awareness and concrete progress (Gallwey 2001; Patterson et al. 2007).
It’s easy to give clients too much information and too many tasks too soon. After all, good nutrition and fitness habits are seamlessly integrated into your life. Remember that clients will take many self-conscious, hesitant and difficult steps in the beginning. In the book The Power of Less (Hay House 2009), Leo Babauta argues that if you give one clear task, 85% of clients will stick to it. Add a second task and adherence will drop to less than 35%. Three tasks—pffft. Now you have less than 10% success. Start with one habit—ideally one that’s small, manageable and practical. When in doubt, simply reduce the task and difficulty by half. If you want clients to eat two vegetables a day as their first task, start with one vegetable instead.
Ask, Don’t Tell
One reason people fail to comply with doctors, nutrition professionals and fitness professionals is that far too often we don’t ask—we tell:
“Take two of these a day.”
“Eat two servings of this every day.”
“Exercise 5 hours this week.”
How well do you respond to being told what to do? Research shows that both animals and humans react defensively when they perceive a strong threat to their freedom of choice. Also, deeply forbidden things are more appealing than requirements. Tell a client “Don’t do that!” and you’ll get a primal-brain-fueled rebellion (Iyengar 2010; Miller & Rollnick 2002).
Luckily, as humans we will tolerate a mild threat to our choice as long as we feel it was our idea and/or it matches our own priorities (Iyengar 2010; Miller & Rollnick 2002; Wlodkowski 2008). Begin with identifying what is truly important for a client—it may not be what you presume. Keep asking, because often the first answer the client gives you is a thoughtless one.
To get into our clients’ heads, we use the “5 Whys” exercise, originally developed for the Toyota production process. It’s a way to get at root causes and effects by asking “Why?” (Ohno 1988). For example:
Client: “I just can’t eat a healthy diet.”
Client: “I don’t feel I was cut out for it.”
You: “Really, why so?”
Client: “Well, um, it’s just hard for me to do, with all the planning.”
You: “Why is the planning hard for you?”
Client: “It seems hard to juggle with all my work demands and stuff.”
You: “Why so?”
Client: “I feel there’s no time to go shopping, with my commuting, and the kids, and Bob working longer hours.”
Now you’re getting somewhere. You can start to see where you as the coach or trainer can intervene at critical junctures; for example, by helping the client work on time management, food preparation strategies and ways to eat healthy meals on the run. You also get a sense of other priorities (e.g., work and family) that are competing for the client’s attention.
Shrink the Change
Usually clients don’t ignore suggestions out of spite. Most simply don’t think some actions are possible or sufficiently meaningful. A die-hard carnivore might find “eating five vegetables a day” as momentous a task as climbing Mt. Everest. Why not ask for a client’s feedback before deciding what advice to give? When was the last time you asked the following:
“What’s truly important to you right now?”
“In what ways do you feel ready to change?”
“On a scale of 1–10, how confident are you that you can do what I am asking?”
In our practice, we ask this last question of each client. It not only helps us shape our advice but also enlists the client in the change process. For example, if the answer is less than a 9 or 10 on a given task, we know the client won’t do what we’re asking, so we make the task easier. In fact, we keep simplifying, clarifying and reducing the difficulty until we get a heartfelt 9 or 10 on the confidence scale.
Research shows that people always want to feel they have choice and to feel in charge of their own lives. View your clients as collaborators and yourself as a guide or facilitator rather than an expert. Highlight where they feel confident and start there (Duncan 2005; Wlodkowski 2008).
How Does All This Work?
The information presented here isn’t just theoretical knowledge. This advice is tested and true. In fact, we’ve successfully implemented these principles in our Lean Eating coaching program, a popular nutrition and lifestyle initiative. Using these principles of effective change, our clients—over 6,000 of them to date—do what we ask of them an amazing 71% of the time. As a result, they’ve achieved (and maintained) a weight loss of over 120,000 pounds!
In conclusion, here are the key principles we’ve covered:
1. Change is hard. Understand that in asking clients to change, you’re asking them to go against basic brain circuitry that normally favors safety and security.
2. To prepare a client for change, you need to
- speak to the client’s rider (the rational-judging brain);
- guide the elephant (the intuitive-feeling-sensing brain); and
- shape the path (the client’s environment and life structures).
3. Inhibit “analysis paralysis” and the critical self. Instead, release and facilitate the “flow self” through simple, meaningful tasks.
4. Make sure any change you suggest is salient to the particular client. Ask questions, listen carefully and try to empathize with the client’s point of view.
5. Choose one practical change at a time, develop it collaboratively and make that change as small and doable as possible.
6. Periodically test and retest the client’s confidence. If the task is too big, shrink it further.
SIDEBAR: Compliance Self-Inquiry
The principles presented in this article are simple to understand and use. In fact, you could use this simple one-habit method in your own practice, starting immediately. Ask yourself the following questions:
- What’s truly important to me in terms of the deeper principles that guide my own practice?
- In what areas am I not living those principles? What limiting factors are preventing me from doing this effectively?
- What is one simple, clear, practical and very small habit I can start immediately?
- How confident am I that I can do this task every day? (If your confidence is less than 9 or 10 on a scale of 1–10, make the task easier.)
After you’ve answered the questions, write your task down on a sticky note, refer to it 10 times today and get going!
SIDEBAR: Be Clear and Specific
When working with clients on goals, remember that any tasks you assign must be clear and specific (Patterson et al. 2007). “Eat better” is no help at all. Even “Eat more fruits and veggies” is too nebulous. Put a number on it. For example:
- Instead of saying, “Work out more,” say: “Do 5 minutes of interval exercise today.”
- Instead of saying, “Eat more vegetables,” say: “Eat half a cup of vegetables with each meal today.”
- Instead of saying, “Improve your posture,” say: “Get up from your chair every hour today.”Subscribe
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