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Resolving to Be Coached

Resolving to Be Coached

The secret to sticking with your resolutions may be having a coach to help strategize and cheer you on.

My teenage patient looked nervous as I reviewed her glucose readings from her glucometer and her glucose logbook, which people with diabetes use to track their blood-sugar test results. There were a lot of high levels — ranges in the 12’s and 14’s, when the goal was around 7 or 8. The peaks were mostly in the middle of the day and on weekends. (This was in Canada; blood glucose readings of 12 to 14 are equivalent to 216 to 250 mg/dL in the United States.)

“What do you usually eat at home?” I asked. She said that her mother was careful to make her a breakfast that balanced carbohydrates with protein. Her dinners were similar.

“What do you usually eat at lunch?” I asked. My patient started tearing up. She ate whatever her friends were eating in her high school’s cafeteria that day — like spaghetti, hamburgers or pizza, and something like a cupcake for dessert. This was probably what led to her readings being so high.

She had met with diabetes educators before, and she knew what uncontrolled glucose does to a person with diabetes, from speeding up nerve damage in the feet to hastening blood vessel damage in the back of the eyes and the kidneys, to increasing her risk of heart disease.

I knew she could have told me all of that, so lecturing her wasn’t going to help.

Instead my patient needed empathy and the tools to help her make healthier decisions, and part of that required understanding what was important to her, specifically “fitting in” with her friends in high school, the ones who didn’t have a chronic disease. It also would have involved helping her find the motivation within herself to make the change.

But my skill set for helping her was limited, especially on top of everything else I had to cover within our allotted time of 45 minutes.

Research suggests that behavioral and lifestyle factors are a big part of what contributes to chronic disease. In medical training, we learn a lot about the body and how to prevent and treat disease, but little about how we can motivate a patient to change old habits or even stick with a current management plan.

It struck me that what my patient really needed was a coach. At this time of year when many of us have made resolutions to get healthier, working with a health coach might be one way to reach those goals.

A health coach is someone trained in behavior change, who primarily uses an interview style called “motivational interviewing” to help patients see their ability to make change. While some may have clinical training in fields like nursing or medicine, they hail from a wide variety of disciplines or train in health coaching as a secondary career.

As a relatively young field, it’s still finding its footing — for instance, a systematic review found that the definitions of “health coaching” varied widely, though the authors recommended that health coaches take a patient-centered approach to help with goal setting while encouraging self-discovery and accountability.

The evidence that health coaching may spur general lifestyle changes is mounting. A 2018 study looked at clinical trials for coaching for nutrition and weight management and found that over 80 percent of these studies found improvement. And a 2017 study found that coaching can lead to increased physical activity in older adults. Studies suggest that health coaching may also provide benefits for conditions such as obesity and diabetes as well as attention deficit hyperactivity disorder, chronic pain, hypertension and high cholesterol. A recent review found that health coaching can improve quality of life and reduce hospital admissions among patients with chronic obstructive pulmonary disease, and it may help patients to become more engaged in the health care system.

It may even improve health outcomes through encouraging patient adherence to medication.

“Health coaching recognizes that we cannot help people by expecting them to act if that person is not ready to act,” said Leila Finn, a health coach based in Atlanta. “We help people take big goals and break them down into accessible, bite-size pieces — not by telling clients what to do but by helping clients figure out what will work for them.”

Health coaching gets to the heart of what providing good health care is about: acceptance, partnership, compassion, and helping patients feel respected and understood.

Though my clinical training is in pediatric medicine, inspired by what I had read, I recently completed a certificate in health coaching myself. The experience was eye-opening and humbling. I learned new ways of communicating with my patients, specifically ways to encourage them to see their own ability to make lifestyle changes while setting manageable goals. I also learned ways to cheer them on when they reach their goals, without shaming them if they relapse: Both pieces are critical to the process of making sustainable change.

While research is beginning to show the value of health coaching, the principles of communicating with the intent to inspire and motivate are transferable to all health professions — and could reap dividends if taught early on in the training of nursing students, medical students, pharmacy students, and other allied health professionals.

And when I think back to my teenage patient with diabetes, while I was empathetic, that was only half of the solution. The second half could have involved coaching her to see which small changes she could begin to make moving forward. I’m hoping that choosing my words more effectively, even within the pressures of time, may make all the difference for my other patients.

**Originally published in the New York Times**

The Power of Surfing, as Therapy

The Power of Surfing, as Therapy

Surf therapy programs often focus on children with autism or anxiety, or groups like veterans or cancer survivors.


Agatha Wallen’s son, Mason, has autism, and when he was 7, she heard about an initiative in San Diego aimed at children with special needs. It involved an unlikely tool: a surf board.

She wasn’t sure how it would work for her son, who struggled with behavioral and sensory issues. “Even getting the wet suit on was difficult for him because it was a brand-new sensory sensation,” she recalled. “From the beach I could see the surf instructors calmly speaking to him, and his whole body seemed to change and relax,” Ms. Wallen said. “He was able to stand up and catch a wave, with a big smile on his face, and ran up to shore and said ‘Mommy, I want to do it again.’”

Mason has been surfing for five years, and now his younger brother, Trevor, 9, is also an active participant in the same program, A Walk on Water. It is a California-based surf therapy nonprofit that primarily focuses on children with special needs — mostly with neurological disabilities. Ms. Wallen serves as an ambassador for the program, helping explain surf therapy to other parents.

“In the ocean there are no cars or planes or people shouting or things buzzing around,” she said.

“It might be the calmness of the waves, but it’s also being with instructors that he could trust and who were patient with him as well.”

A Walk on Water’s executive director, Sean Swentek, points to the importance of serving the whole family, including the child’s siblings, while also offering respite for parents.

“Surf therapy often provides bonding time for them, and our events are meant to be a full day of healing for the whole family,” Mr. Swentek said. The group recently released a short documentary about the role of surf therapy in the lives of three children with special needs.

“In a nutshell, surf therapy is a structured method of surfing utilizing elements of ocean and using its therapeutic benefits for those in need,” said Kris Primacio, the chief executive of the International Surf Therapy Organization, which acts as an umbrella organization to bring together surf therapy programs and researchers. “We tend to focus on underserved populations and exposing surf therapy to those who wouldn’t otherwise have access to an instructor.”

Each surf therapy organization develops its own program. In general, groups meet on the sand before a surf lesson, discuss ocean safety and often discuss mental health struggles as a form of group therapy. They then surf for a few hours and have a debriefing session.

In Britain, children with referrals for anxiety can participate in a free six-week program called The Wave Project. The program, which has received National Health Service funding in the past, gathers data before and after through questionnaires using the Stirling Children’s Well-being Scale and the Rosenberg Self-Esteem Scale.

“We focus on children who have anxiety disorders or are at risk of developing issues. Some may have autism or A.D.H.D. and are at risk of developing more series mental health problems, and most of these children feel isolated,” said Joe Taylor, the program’s chief executive. “Our approach is similar to an occupational therapy approach, and we don’t see ourselves as an alternative to support for care, but part of a package of mental health care.”

In 2014, John Newkirk started Salt Water Therapy L.A., which emphasizes mindfulness as well as surfing. As a certified drug and alcohol counselor with his own history with addiction, Mr. Newkirk wanted to share a mindfulness practice while also structuring the program with ocean safety and surf instruction.

“What happens with mental struggles, including addiction, is that there is an element of self-medicating. Surfers have called it ocean therapy for decades, because of the spiritual benefits. It’s a high with dopamine, but a safer healthier kind,” Mr. Newkirk said.

Surf therapy is not a substitute for medical care, and surfers can still struggle with mental illness. Indeed, the surf legend Sunny Garcia talked about his depression and has been hospitalized since attempting suicide this spring.

However, the evidence for surf therapy seems to validate what we know about movement and exercise, therapeutic effects of water and mindfulness. For instance, two years ago, a paper out of California State University described that just one 30-minute surf session improved mood, but the researchers didn’t distinguish the impact of surfing compared to other sports.

A qualitative study of 22 youths participating in The Wave Project, published in June in the International Journal of Environmental Research and Public Health, noted that surf therapy may work through offering a safe physical and emotional space, peer mentoring and positive reinforcement. Similarly, in 2017 a British study looked at the effectiveness of a three-month surfing program for youth and found that some elements of self-reported well-being improved. However neither study matched participants with a control group.

In June, research with 74 active duty military personnel from the Naval Health Research Center in San Diego found that depression, anxiety and PTSD symptoms decreased after surf therapy, but all participants were simultaneously receiving another form of therapy, making it hard to measure the impact of surfing alone.

Naturally, surfing is not without dangers: drowning, rip currents, sharks, just to name a few.

“The ocean is unpredictable, but leading organizations try to mitigate the risks by making sure staff are C.P.R.-certified and know how to prevent and deal with emergencies,” Mr. Swentek told me. “I think part of the reason it’s so powerful is because of those risks. It is not easy to do, so when these kids for instance are able to surf a wave and overcome their fear, there’s huge growth.”

Is the trend of surf therapy meaningfully different from exercise or mindfulness techniques? The evidence isn’t quite there. But its popularity is a sign of broader interest in a variety of tools that might improve mental fitness. Notably, a Los Angeles-based study from 2014 found that surfing may have a positive effect when delivered in combination with other forms of exercise, medication if needed, and group or individual therapy.

In Jon Kabat-Zinn’s book on mindfulness “Wherever You Go, There You Are,” he writes, “You can’t stop the waves, but you can learn to surf.” Dr. Kabat-Zinn, a physicist by training, was one of the first academics to standardize and research mindfulness approaches. In surfing, much of the challenge involves facing a real wave and pushing forward anyway, even when the easy thing to do is back away.

When I reached out to Dr. Kabat-Zinn to say that one of his best-known sayings was being taken quite literally, he replied in an email:

“The beauty of mindfulness is that you can bring it into anything, and then everything becomes your mindfulness teacher and contributes to waking you up fully. Surfing is no exception. When you are really present, the world (and the wave) can wake you up, and bring you into the timeless present moment, even in the midst of complex, unpredictable, dynamical circumstances.”

**Originally published in the New York Times**