By Lisa Renn
“Our deepest fear is not that we are inadequate. Our deepest fear is that we are powerful beyond measure…” Marianne Williamson
When working with clients it’s possible to be baffled at times by people desperately wanting to improve their health or their situation however not being able to comply fully with their own plans or those set by a clinician. At the outset I am making the assumption the health plans devised are reasonable, evidence based and not unrealistically restrictive.
Understanding that fear is often at the base of this lack of progress can help you deepen empathy for your clients and possibly help them past this. While it is certainly true there are many possible explanations for why people don’t take action on their goals fear is worth remembering as a high possibility. When I mention fear I’m not talking about fear of an eminent attack or threat, I’m talking about fear of failure or fear of the unknown.
Lou Heckler, a US based speaker, was telling a story of how he applied for and successfully got a job that he was not really sure he could do. He said to his mentor “I’m scared, I’m not sure I can do this job.” His mentor replied “If you’re not scared it’s not hard enough.” Powerful advice and reassuring for a motivated and confident person but what about clients who have not had great successes in their life to build their own self confidence from?
Examples of how fear can manifest itself:
· What happens if “they” say “Why didn’t you do this before? What’s taken you so long, why did you stay at that weight if you didn’t need to?”
· What happens if I can’t keep the weight off and it all goes back on? What would people say then?
· If I change people may not like me anymore? What will happen to my old friends?
· If I change it will affect my relationship, my partner doesn’t like it when I try to lose weight.
· If I lose weight I will have to live out my dreams and that is scary and I’m not sure if I can do it.
· If I lose weight I may attract unwanted attention
· If I lose weight I may not be able to protect myself as well.
Fear of the unknown makes people want to stay the same as it’s a known quantity. It appears that humans will avoid pain before we will seek pleasure. In this way our fear can hold us back because of the “What if” factor.
· I can’t do it?
· It doesn’t make me happy?
· I can’t keep it up?
· Things go wrong?
· I don’t like myself on the other side?
· People don’t like me?
· People disagree with me?
We like to avoid the pain of the unknown and stay with what is safe and known even if we don’t really like it- at least it’s comfortable.
“Fear is like a puddle, only those who jump in will ever know how deep it is”
Looking at this quadrant model consider that fear is based on self-efficacy, that is the belief the individual has in themself and their ability to carry out the plan and the level of trust they have in the people around them and themselves. The position that a person finds themselves in is most certainly based on past experiences and how the individual chooses to reference these past events.
High Self-Efficacy & Low trust:
This person is hesitant and likely to be represented by a large number of your clients, although they have good self-efficacy and know they could do what is required the “What if” factor plays a big part in their hesitance to act. It is much easier to stay the same than change and experience the unknown.
This person is in a great position to change and just pointing out to your client that sometimes people are hesitant to change as they are fearful of the consequences of changing. Asking what they believe the consequences of change would be may assist them to start to focus on action rather than the perceived, yet unknown, outcome. By talking openly to a trusted advisor about these thoughts people can be assisted to see the irrational parts of their thinking. With awareness comes the possibility of change and a new focus on action.
“Fear is like the monster under the bed, it diminishes under close examination.”
Fear can be masked by labels people give themselves.
· “I’m lazy”,
· “I’m the kind of person who eats the whole packet”,
· “I’m addicted to …”
If someone is saying I could do this but…talk to them more about the reason they have given. Propose the idea of fear at the same time reassuring them that fear is a perfectly normal part of change.
Low Self-Efficacy & Low Trust:
This persons inner dialogue is telling them “I can’t handle this” I t may be a passing stage due to the shock of a diagnosis or being overwhelmed with other stresses in their life at that particular time or it may be they have tried and failed so many times before they truly believe the outcome you are talking about is not achievable for them.
The client may present emotionally or present as very willing to hear you out and agree with the goals you have set down together – but on review they have not been able to make the changes.
The aim is to increase this person’s trust and affirm their strengths. It is through this process that you are able to improve rapport and start to move them to concentrate on their actions- what they actually have to do instead of just thinking about what has happened in the past.
Their fear is real as they don’t know what to do nor do they believe they can do it. It is not the most hopeless position as you can build trust, self-efficacy and knowledge together to help the person move from their feeling of paralysis.
When you start to recognise fear as a basis for lack of action it’s a good idea to reassure your client that you don’t expect miracles, that if things aren’t working that’s the most important time to come back, that you won’t be judging them and to mention the possibility that the problem may be a “what-if” fear. Reassuring people they are normal, that everyone is hampered by “what-if’s” at some point. Doing some work on skills and strengths to gather evidence to contradict their current beliefs could also be helpful.
Low Self-Efficacy & High Trust:
This client trusts in the process and understands that it will work for others but they do not believe they are capable of getting the same results. In essence they are accepting of their situation and believe that it is unlikely they can change.
A person who feels this way you may only see once and not return as they “know” they won’t be able to comply with the goals you have negotiated together or they may continually come to see you but each time they have reasons why they couldn’t carry out the negotiated goals.
There are three clients I think of who fit into this group and they were all different:
Case study 1: One client was referred to me due to a new diagnosis of type 2 diabetes, she presented as interested and engaged in the process. She attended a number of review appointments and didn’t miss any appointments. After a period of time when her blood sugar levels were better controlled with medication and we were talking about her attempts to lose weight she said “I don’t believe that I can lose weight”. This lady had a long history of attempting to lose weight and had accepted her situation as unchangeable.
Case study 2: The person was a long term client who kept every appointment but rarely did any of the tasks we had jointly negotiated at the previous appointment. She signed up for a lot of groups as well and clearly trusted in the process however each appointment she would put the reasons why she hadn’t tried the goals. She had high trust in the process but took no responsibility for her actions.
Case study 3: This client had completed one degree and was in the process of completing her honours year at university. Despite this evidence of capability she still believed that she was not capable of anything and this belief carried over to her perception of her ability to implement health goals. Any slip up was seen as a massive failure and reinforced her belief that she was not capable of change.
Fear of failure is a real presence for many people and will often prevent them from even starting.
The difference between these clients was their locus of control of behaviour – two of these examples did look to themselves (intrinsic locus of control) and felt they couldn’t do it and the other looked to external problems as the reason she couldn’t achieve her goals. Either way action rarely happened or if it did it was not sustained for long. For these women there was a time when they did achieve some of the goals, at this point they had moved to a higher self-belief but all the “what-ifs” were coming in thick and fast and it wasn’t something they could tolerate. Its evidence again that people will do more to avoid pain than they will to chase up pleasure or aspirations.
This is perhaps the most difficult type of client to work with as despite a lot of evidence to the contrary these people have very low self-esteem and don’t believe they are capable. This situation could arise from the relationships in their lives either with parents or partners and their feelings of inadequacy could be being reinforced on a daily basis or be long held beliefs since childhood.
If you find after a number of appointments that you client loves the work you are doing together but is still talking about their inability to change and you have an understanding of where this low self-esteem is coming from but can’t make inroads by pointing out the persons’ strengths and capabilities- it is perhaps time to refer to a psychologist for extra help.
High Self-Efficacy & High Trust:
This client will be telling you about the things they have already done, the goals they have set and achieved. The things they have realised about themselves and the old habits they have ditched so far. You will provide information and they will be keen to hear it and to action it.
This person really only needs your knowledge and some tips and they will be on their way. They take responsibility for their actions and have a positive base of past experiences to build on.
Brian Tracey says that fear can be overcome by learning the habit of courage. Courage can be increased by practising it – repetition.
I like this idea as it focuses on action. It’s not helpful to focus too much on the fear as it is usually irrational and sometimes unrecognised. The client can quite reasonably feel that you as the clinician don’t know how things will turn out either- particularly if you don’t know the family or know the partner or know the history – and realistically it is unlikely that you will know everything. In this way focussing too much on fear will only reinforce the clients fear and make them defend their position of inaction. The goal is to mention fear, explain it and ask questions but not to dwell on it; part of this process is around taking the power away from the fear and the next part is to reassure your client the best way forward is to focus on action.
Practising courage, which is really just focussing on action, and aiming to prove the “what-if’s” wrong is the way forward.
Rosa Parks and African American civil rights activist said, “I have learned over the years that when one’s mind is made up, this diminishes fear; knowing what must be done does away with fear.”
By understanding your client at a deeper level you deepen empathy and rapport and step into your role as trusted advisor. This deeper relationship will lead to better health outcomes for your clients.
Lisa Renn is an Accredited Practising dietitian and behaviour change expert whose passion is helping her clients create healthy habits in the long term. Lisa is the author of “Body Warfare- The Secret to Permanent Weight Loss” (Brolga publishing 2011)which is a “how-to” book assisting people to create long term change and outlines a number of activities that are used in her health professional training program. To register your interest for the next half day workshop for health professionals to be held April 27th, Balwyn VIC. Email firstname.lastname@example.org