I need a 10-12 PowerPoint slide regarding Lifestyle Change

HEALTH AND SPORTS

‘‘I tried so many diets, now I want to do it differently’’* A single case study on coaching for weight loss

REINHARD STELTER, Dr

Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen N, Denmark

Abstract In this single case study, the author presented an in-depth description and analysis of a coaching intervention with focus on weight loss, conducted over 10 sessions in the course of 17 months. The client was a well-educated woman in her late 30s, who had tried many different forms of dieting over the years*with little and no lasting effect. In his coaching approach, the author went beyond a pure behavioural change model, that is, based on the Health Belief Model, and tried to take a whole- life perspective, where the client learned to link specific events and habits in her work life and everyday life with specific eating habits. In their collaborative practice, coach and coachee initiated changes both in regard to diet, physical activity, and healthy life style, in general. In a theoretical section, the change in understanding with regard to overeating was presented. Finally, an intra-active model*viewing the client as a self-reflective individual*was used as theoretical basis. A narrative analysis of the first session and a cross-session examination was presented to show, analyse, and understand the procedure of the coaching approach. Finally, the voice of the coachee was heard in regard to her personal experiences during the process. The data material was based on audio recordings of selected sessions, notes written by the coach from every session, and final written reflections by the coachee.

Key words: Health coaching, life style change, meaning making, case study, overweight, obesity, diet, physical activity,

weight loss

(Accepted: 27 May 2015; Published: 14 August 2015)

By now, we all know that overweight, defined by a

body mass index (BMI*the weight in kilograms divided by the square of the height in meters) above

25, and especially obesity, defined by a BMI of 30 or

more, is a threat to people’s health. On the basis of a

large cohort study, Adams et al. (2006) could con-

clude: Excess body weight during midlife, including

overweight, is associated with an increased risk of

death. The number of people who are overweight

and obese is growing in many countries, led by

the following top 10: (1) USA, (2) China, (3) India,

(4) Russia, (5) Brazil, (6) Mexico, (7) Egypt, (8)

Germany, (9) Pakistan, and (10) Indonesia. World-

wide, the number of overweight and obese people

increased from 857 million in 1980 to 2.1 billion in

2013*an increase of more than 145% (www.health. usnews.com/health-news/health-wellness/articles/2014/

05/28/america-tops-list-of-10-most-obese-countries;

retrieved 7 August 2014). The reasons for this

development are manifold: lack of energy balance,

inactive lifestyle, environmental factors, lack of sleep,

just to mention some of the central causes (www.

nhlbi.nih.gov/health/health-topics/topics/obe/causes.

html; retrieved 7 August 2014). The relationship

between socio-economic status and obesity must be

nuanced depending on the level of development of

the country. McLaren (2007) documented the fol-

lowing as the overall pattern of results in regard to

this relationship: For both men and women, an

increasing proportion of positive associations and a

decreasing proportion of negative associations were

found, as one moved from countries with high levels

of socio-economic development to countries with

medium and low levels of development.

On the basis of these epidemic dimensions, the

issue of overweight and obesity cannot be taken

lightly. It is probably one of the most fundamental

threats that governmental health authorities are

Correspondence: R. Stelter, Coaching Psychology Unit, Department of Nutrition, Exercise and Sports, University of Copenhagen, NørreAllé 51, DK-2200

Copenhagen N, Denmark. E-mail: [email protected]

International Journal of

Qualitative Studies on Health and Well-being �

# 2015 R. Stelter. This is an Open Access article distributed under the terms of the Creative Commons Attribution 4.0 International License (http:// creativecommons.org/licenses/by/4.0/), allowing third parties to copy and redistribute the material in any medium or format and to remix, transform, and build upon the material for any purpose, even commercially, provided the original work is properly cited and states its license.

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Citation: Int J Qualitative Stud Health Well-being 2015, 10: 26925 - http://dx.doi.org/10.3402/qhw.v10.26925

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forced to deal with. Compared to the size of the

challenge, the topic and objective of this article

seem to be a drop in the ocean. The attempt here

was to present a concrete case study with two central

objectives: First, to document and evaluate the

client’s experiences of the change process, based on

the intentions and dialogical strategies of the coach,

and second, to document and analyse the process

and impact of coaching for weight loss coaching

dialogues. The approach presented here used a

broader perspective than a sole focus on perception

of threat as the basis for behavioural change (e.g.,

the Health Belief Model [HBM]), because of the

author’s firm belief that the change in behaviour is

based on new ways of sense- or meaning making,

of understanding oneself, and of attitudes towards

life. This shift in the mindset will slowly prepare the

client and make her ready to initiate the first step

towards a change of lifestyle.

Approaches and procedures for behaviour

change

During the twentieth century, the understanding

of the individual has changed. On the basis of a

better understanding of psychological reasons for

obesity (Swencionis & Rendell, 2012), this change

of understanding also had an influence on the

approaches to helping people with weight loss and

lifestyle change (Ogden, 2002). (1) During the first

half of the century, the main approach assumed

that the individual was passive, and behaviour could

be predicted and influenced through specific stimuli

(Pavlov, 1927; Skinner, 1953). (2) From the 1960

onwards, the behavioural law of conditioning was

substituted by emphasizing ‘‘an interactive alignment

of the individual and their environment’’ (Ogden,

2002, p. 21). Individuals were understood as being

able to process information, and on the basis of their

cognitive understanding they could make changes

in their behaviour. This understanding can be seen

in the HBM (Daddario, 2007; Rosenstock, 1974).

Very briefly described, the model stated the following:

Perceived seriousness and perceived susceptibility

with regard to specific health threats might lead

to growing awareness of possible health threats,

which might enhance the likelihood of engaging in

health-promoting behaviour. In a further develop-

ment of the model, self-efficacy (Bandura, 1977,

1997)*the confidence that a desired behaviour can be carried out*was included as an important factor for change (Becker & Rodenstock, 1987; Rosenstock,

Strecher, & Becker, 1988). (3) In a way, the further

development of the HBM was the first indication of

the third phase in the understanding of the individual;

a phase that was inspired by poststructualism and

which had become more and more prominent during

the last two decades. Ogden (2002) described the

shift by presenting the reflexive, intra-active individual,

a term fairly new in the literature, which Ogden

(1995) had already described as follows:

The contemporary intra-active individual is

characterized by an agency and an intention-

ality which is directed internally towards their

inner self. The late twentieth century object of

psychological thought has become a subjective

entity whose subject is the self. (p. 412)

The neologism ‘‘intra-active enactment,’’ intro-

duced by Barad (2007), who was inspired by Michael

Foucault and Niels Bohr, was related to the idea of

a growing subjectification in today’s society. Højgaard

and Søndergaard (2011) wrote:

The concept of subjectification builds on the

work of Michel Foucault, his conceptualisation

of discursive power as productive, and his point

about subjective submission under discursive

power as a process which involves a simulta-

neous production of subjective existence and

agency. The humanist idea of a ‘‘core self ’’ is

radically transgressed in this line of thought

and replaced by the idea of an emerging

subject. The basic figure of simultaneity be-

tween submission and agency in the formation

of the subject has had an enormous impact on

poststructuralist thinking over the past decades.

(p. 340)

In that sense, subjectification is a concept that

describes individuals as agents who simultaneously

shape whatever they are shaped by. In a similar way,

subjectification describes the growing impact on the

individual’s handling of specific social and personal

challenges in regard to health issues such as smoking,

diet, weight loss, and involvement in physical activ-

ities and sports. In regard to these challenges, the

subject tends towards various forms of surveillance,

a phenomenon that Foucault described as constant

and pervasive forms of observation that finally lead

to growing individual self-control. Individuals be-

come their own ‘‘worst enemy.’’ From this perspec-

tive, there are indications in the literature of the

critical influence of monitoring weight on psycholo-

gical states (Dionne & Yeudall, 2005; Ogden &

Whyman, 1997).

The intra-active overeater

On the basis of this intra-active model of the self,

Ogden (2002) described the change in regard to the

understanding of dieting as follows. In the 1960s and

R. Stelter

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Citation: Int J Qualitative Stud Health Well-being 2015, 10: 26925 - http://dx.doi.org/10.3402/qhw.v10.26925

1970s, the psychological understanding of overeat-

ing was influenced by the idea that overweight

and obesity were highly and sometimes uncontrol-

lably responsive to external and environmental cues

such as time of day, sight, number and salience of

food cues, and taste (Schachter, 1968; Schachter &

Gross, 1968). In the last quarter of the twentieth

century, new models emerged. Ogden (2002, p. 87)

referred to studies conducted with normal weight

individuals, studies which ‘‘suggested that trying

to eat less (i.e., restrained eating) was a better pre-

dictor of food intake than weight per se.’’ A theory of

restrained eating behaviour evolved. The perception of

weight, a biological construct, was no longer seen

as the main determinant of eating behaviour. Instead

restrained eating, a psychological construct, was in-

troduced as means to evaluate food intake (Herman

& Mack, 1975; Hibscher & Herman, 1977). In

consequence of this approach, overeating could be

characterized as a failure of self-control (Ogden, 1997,

2002); the individual does not manage to keep him-

or herself under ‘‘proper’’ surveillance. This led

to the development of to an escape theory to explain

disinhibition with the consequence of overeating

(Heatherton & Baumeister, 1991): Binge and over-

eating arise as part of a motivated attempt to escape

from self-awareness and self-control in situations

where one’s own high standards and demanding

ideals are put under pressure. Eating turns into pure

relief for surveillance and becomes self-satisfactory.

In a study of Heatherton and Baumeister (1991,

p. 101) binge eating was also ‘‘associated with

decreased negative affect.’’ On the basis of this

understanding, Ogden (2002, p. 89) concluded:

‘‘Therefore, a shift to lower self-awareness resulted

in reduced self-control’’*with the final possible con- sequence: overeating. Her definition of the indivi-

dual ‘‘as a reflexive, intra-active and self-controlling

self, who is not biomedical and not social’’ (Ogden,

2002, p. 97) was an attempt to overcome the dualism

or disintegration between social and environment

dimensions on the one side, and individual and

psychological dimensions on the other side. With

this model, the intention was to merge the individual

with social and environmental factors. Individuals

become reflexive and intra-active subjects and ob-

jects of their own self-reflection (Figure 1). Indubi-

tably, environmental factors have an impact on the

individual but not in a simple causal relationship.

Højgaard and Søndergaard (2011, p. 347) saw the

concept of intra-action as ‘‘premised on a concep-

tion of radical co-constitution of subjects as part of

material-discursive enactments.’’ Intra-active theor-

ists see individuals embedded in a specific social

discourse of, for example, being slim, looking good,

controlling one’s weight, being physically active, etc.

as well as in discourses such as ‘‘when I am unhappy

or under pressure, eating helps me to feel satisfied.’’

All these discourses generate intra-active movements

in the individual as a form of material-discursive

practice, for example: ‘‘I eat fast food or sweets to

calm down when I come home after a stressful day

at work.’’ This practice becomes meaningful for

the individual. Repetition underlines this meaningful-

ness and becomes the motor for the performativity

of, for example, binge eating. The concept of intra-

action takes the complexity of the individual’s world

into account by embracing the diverse factors of

the material, social, and subject world.

This theoretical understanding was assumed to be

helpful for the further understanding of coaching

as a dialogical tool for self-reflection around eating

and striving for weight loss. Coaching should be

seen as an integrative part of the individual’s intra-

active process where new material-discursive prac-

tices are initiated; practices that simultaneously

express and enact new meaning and understanding

in regard to the complexity of the client’s life. The

intention of coaching for weight loss should replace

self-surveillance with a self-understanding that helps

clients manage their own life in a way that enables new

dimensions in regard to handling specific challenges.

Coaching as the basis for changing eating habits

If we see the lack of self-control as the greatest

hindrance to weight loss, then individuals who wish

to change their eating habits have to get involved

in a self-reflective process, in our case offered through

coaching, which may be seen as the basis for a new

material-discursive practice. Based on the presented

intra-active approach, it would not work simply to

focus on the goal of weight loss and pursue the direct

Figure 1. The intra-active individual.

A single case study on coaching for weight loss

Citation: Int J Qualitative Stud Health Well-being 2015, 10: 26925 - http://dx.doi.org/10.3402/qhw.v10.26925 3 (page number not for citation purpose)

path towards a change of behaviour. A goal focus on

weight would only keep the person’s attention on

self-surveillance and self-control. It is not enough

to understand the perceived seriousness and the

perceived susceptibility to personal health issues,

for example, in regard to overweight (as suggested

by the HBM). Instead, individuals striving for weight

loss are invited by the coach to see themselves from

a new perspective and somehow learn to grasp the

complexity of their world in a new way. They have

to take a closer look at themselves as being co-

constituted as both a subject and object of their lived

practice.

In the following, a definition of health coaching

is presented on the basis of the current review of the

literature. Further on, the author will unfold the

fundamentals for coaching for weight loss that takes

the approach of the intra-active overeater into account,

and that is seen as the more effective approach than

the traditional narrowly goal-oriented approaches.

Wolever et al. (2013) have published a systematic

review of the literature on health and wellness

coaching, observing an emerging consensus in what

is referred to as health and wellness coaching. On the

basis of their literature study, they define health and

wellness coaching as

a patient-centered approach wherein patients

at least partially determine their goals, use self-

discovery or active learning processes together

with content education to work toward their

goals, and self-monitor behaviors to increase

accountability, all within the context of an

interpersonal relationship with a coach. (p. 52)

They continue by presenting patients or clients

as ‘‘as lifelong learners whose individual personal

values and innate internal resources can be cultivated

in the context of a supportive relationship to guide

them toward their own desired vision of health’’ (see

also Smith et al., 2013, p. 52). Based on this under-

standing, an approach to coaching for weight loss

will be unfolded by emphasizing the self-reflective

dimension of the dialogue, by highlighting personal

values and meaning making and finally, as a result

of this reflective process, by preparing for change of

behaviour (see also Stelter, 2007, 2014). The use

of this approach will be illustrated in the later des-

cription and analysis of the case study with Anna.

In the following, a number of central criteria for this

self-reflective coaching for weight loss approach will

be presented:

(1) Raising the level of the dialogue to meaning

making: Making meaning of life events, action

patterns, and specific habits*good or bad*is the pivotal point of a self-reflective coaching

dialogue. Meaning emerges twofold by inter-

linking individual with social meaning making.

Based on phenomenological thinking, indivi-

dual meaning making unfolds by making sense

of specific experiences and (bodily) sensations,

by bringing the pre-reflective (e.g., habits

and routines) to the surface of the reflections

in the dialogue (Stelter, 2000, 2008; Stelter &

Law 2010). Learning to be mindful by sensing

what happens in specific situations and in

regard to (re)establishing new habits is a central

dimension of individual meaning making.

Based on social constructionist thinking,

social meaning making evolves by making

sense of and reflecting on the impact of

specific social relations, specific others, and

the social context in general on one’s identity

and one’s way of being in the world (Gergen,

2009). We co-construct the world through

and in the relationships with others.

(2) Focusing on values: Values embrace the most

central and fundamental issues in our life

and are*often implicitly*guiding markers for our way of acting in the world. Too often,

coaching takes its point of departure in a

specific goal [e.g., in the GROW model

(Goal-Reality-Options-Wrap-up; Whitmore,

2009), or in motivational interviewing], but

goals are at the lowest level in the hierarchy

of intentionality (Stelter, 2009, 2014). On

the next higher level, ‘‘purpose’’ is the dimen-

sion that goals are influenced by, and on the

crown floor of the hierarchy of intentionality

we find the dimension of meaning making,

which inevitably leads to a reflection on values

(Stelter, 2007, 2014). To do successful coach-

ing interventions, it is important to build

bridges between the clients’ ambitions to

change their way of living and their specific

individual values, which they can investigate

on their journey, and which in the end can

lead to a change of behaviour.

(3) The narrative-collaborative dimension of

coaching: Meaning and values are often

embedded in specific episodes and events.

As part of a transformative learning process

(Illeris, 2004; Mezirow & Associates, 1990),

where learning always implies an impact on

identity and self-understanding, coaching

becomes a collaborative enterprise between

coach and coachee. The narrative element is

highlighted by connecting the coachee’s ac-

tions with identity issues and vice versa.

Narratives are the vehicles which link specific

events in a timeline and which have a special

impact on the client. If these narratives are a

R. Stelter

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Citation: Int J Qualitative Stud Health Well-being 2015, 10: 26925 - http://dx.doi.org/10.3402/qhw.v10.26925

strain on the client, the aim is to deconstruct

them in the collaborative process between

coach and client. Deconstruction implies

the potential for change. By reflecting on

the narrative and presenting additional pos-

sible interpretations, the dialogical partner

applies procedures that undermine the taken-

for-granted understanding of the client’s life

and identity (White, 2004).

The author was aware of the close connection

between the self-reflective dimension of the dialogue

and the focus on the final goal: weight loss. The path

in the GROW model, or motivational interview-

ing (Rubak, Sandboek, Lauritzen, & Christensen,

2005) appeared to be too goal-focused with too little

attention paid to possible barriers and the complex-

ity of life, which are more thoroughly dealt with in

an in-depth, self-reflective coaching process based

on the three key areas presented above.

Methodological reflections in regard to the

single case study

In this case study, the intention is to present the

whole picture of a single case on coaching for

weight loss (more on case study design, Yin, 2009).

The research documentation in the form of this

article was NOT at all planned beforehand; it was

only decided a few weeks before the last session in the

coaching process. 1

As mentioned earlier, the objec-

tive of this case study is twofold: First, to document

and analyse the process and impact of coaching

for weight loss dialogues, and second, to document

and analyse the client’s experiences of the change pro-

cess, based on the intentions and dialogical strategies

of the coach. To be able to meet these objectives,

the following data material was included:

(1) Notes taken by the coach during each session

(this is a standard procedure).

(2) Audio files of the first six sessions (it was

actually the client who asked for permission

to record the sessions).

(3) Reflective notes, produced by the client

before the final session.

The material is used in different ways. To provide

a basic understanding of the coaching process,

the first session is presented as a narrative that is

developed on the basis of an analysis of the coach’s

notes and an audio-recording of the session. The rest

of the process is examined in a critical analysis of the

coach’s notes and the audio-recordings. Finally, the

client’s reflections are presented in their original

form as a written narrative submitted to the author.

In the concluding section, the author’s and the

client’s respective analyses are compared, and some

final conclusions are presented.

Narrative analysis of the first session

The narrative presentation of the first session unfolds

on the basis of an analysis of the researcher’s notes

and of the audio-recording of the session. Specific

events and situations were chosen and highlighted

to make the narrative coherent while remaining

faithful to the data. This process of shaping the

storyline was part of the interpretation and analysis

of the qualitative material. As in any qualitative

analysis, a major effort is done to achieve credibility.

The intention was to use Richardson’s (2000, p. 923)

idea of writing and storytelling as a way of analys-

ing interview material: ‘‘Writing is also a way of

knowing*a method of discovery and analysis. By writing in different ways, we discover new aspects

of our topic and our relationship to it. Form and

content are inseparable.’’ The narrative�analytical perspective used was that the researcher had to

develop meaning out of the material.

Cross-session analysis

Subsequently, the entire sequence of sessions was

analysed by coding the notes and the speech from

the audio-recording of the session, thus extracting

the central meaning and forming central themes that

represent the core issues of the series of coaching

sessions. The idea of writing the narrative down was

also applied in this section by combining the pre-

sentation of themes with a reflective analysis that

includes the theories presented earlier.

The case study as practitioner research

The case study should also be understood as the work

of a practitioner researcher (Jarvis, 1999) or a scientist

practitioner (Lane & Corrie, 2006), meaning that the

author sees himself both as a researcher and reflective

practitioner (Schön, 1983; in regard to coaching: see

especially Stelter, 2014). Lane and Corrie (2006)

defined the ability to formulate the actual case based on

its inherent challenges as one of the most essential

qualifications of a psychologist or a coach. They saw

this process as a form of psychological sense-making,

which can be understood as a central criterion for

reflective practice and thereby for the development of

expertise as professional.

Case study: Anna’s path towards weight loss

In this single case study, the author presents an in-

depth description based on an analysis of a coaching

A single case study on coaching for weight loss

Citation: Int J Qualitative Stud Health Well-being 2015, 10: 26925 - http://dx.doi.org/10.3402/qhw.v10.26925 5 (page number not for citation purpose)

intervention with focus on weight loss, conducted

over 10 sessions spanning the course of 17 months.

The last session was in September 2014. The client,

we call Anna, a well-educated woman in her late

thirties, has tried many different forms of dieting

during her adult years*with little and no lasting effect. First in the very final phase of the coaching

process, the author decided to publish this work* with the full approval of Anna, who even agreed to

participate in this publication with her own reflec-

tions written just before the last coaching session,

a reflection that was also included in the session to

help her planning her future path.

Anna contacted me after she had participated in

a coaching workshop of mine, where she became very

interested in my work and my approach. Through

email, we agreed on having at least five meetings,

but we ended up having 10. Her decision to start

coaching for weight loss with me was supported by

her conviction that my coaching approach might

help her more than all her former attempts and

strategies towards weight loss, which had not really

satisfied her, and which did not live up to her ex-

pectations in regard to losing weight and maintaining

the success. She also stated a fundamental principal

for her: She does not want to lead her life in a state

of permanent dieting. Food intake should be a plea-

surable part of her life. Her ambition was to lose up

to 25 kg. Here is the narrative of the first session,

a narrative that shall also help the reader to get a

basic impression about how coaching was conducted:

The first session

A Friday afternoon in April 2013, Anna enters my

office. She quickly starts talking about her life. She

feels that since her childhood she has eaten too much

candy, especially when spending time with her grand-

parents, which she has done quite a lot. When her

grandmother died, she was quite depressed for a long

period of time. ‘‘But I ‘woke up’ again and actually

lost weight. I overcame it, and life was more ‘bubbly’

and good. But after writing my master’s thesis I have

gained weight again. I lost control. I must get it

stopped! But I have a hard time doing it myself,’’ she

states with a hint of despair.

She begins to talk about her work: She says that

she should actually be very pleased with her job.

She uses her university degree and has a good

position in the organization. ‘‘But I feel sapped. I

don’t use myself in the right way. I am not on the right

shelf. My job holds no meaning for me.’’ In spite of

this slightly discouraging assessment, she at the same

time ensures me that her boss is very pleased with

her. She considers herself to be a very valuable and

well-liked employee. ‘‘Even though I am very much a

perfectionist when it comes to my work and often

work both in the evenings and the weekends, I don’t

experience my job as being meaningful! I just can’t

do my best.’’

She tells me that she has gone through a short

coach training in 2010 and would like to develop a

concept concerning coaching the 60 plus age group,

where she would like to help people in their transition

from work life to retirement, ‘‘the third age.’’ She

feels that she has developed many competencies

within the field of coaching, and she does work with

coaching on a small scale. ‘‘I began to see the world

in a different way,’’ she says. ‘‘But the coach training

has made me feel that it’s wrong for me to be doing

my current job.’’

We talk about what it is about coaching that attracts

her, and how coaching helps her experience meaning.

She tells me that she has always been interested

in performance art, relations, and other people. It is

within this field, she wants her future to be.

She talks about the challenges she faces in regard

to her weight. ‘‘I strive for the perfect image. I either

lose weight for real or else I might as well not

bother!’’*‘‘But I have the feeling that I don’t take myself seriously.’’

I ask her to tell me more about her job. She says

that she often works up to 60 h a week (and here we

are talking about a regular ‘‘37 h a week’’ job more or

less.). She explains that she often works more than

her boss, who usually goes home around 4 p.m. and

doesn’t read emails during the weekend. In a humor-

ous way*with the hope she will be slightly provoked in a good way*I say to her: ‘‘So sometimes, it is as if you have IDIOT stamped on your forehead when

you see your boss go home before you.’’ ‘‘Yes, actually,

you are right; I can see that sometimes I do have

IDIOT stamped on my forehead.’’

‘‘To me it seems like you don’t take proper care

of yourself,’’ I say with a tone of understanding. ‘‘Yes,

those words are very fitting: I need to take proper

care of myself,’’ Anna confirms my statement, clearly

impressed by how well I capture the essence of her

life situation. I talk a little more about taking care of

one’s self: ‘‘It is also manifested in the way you take

care of yourself, also in regard to cooking, exercise,

and a healthy lifestyle. It is important that you enjoy

things and allow yourself the time for it.’’ ‘‘Yes, you

are absolutely right, I don’t take myself seriously.’’

To get a sense about taking herself seriously, I ask

Anna the following question: ‘‘On a scale from 0 to

10, where 0 is ‘I don’t take myself seriously’ and 10 is

‘I take myself very seriously’, where are you in regard

to work on the one hand, and in private on the other?’’

Anna answers with conviction as follows: ‘‘At work

it is a 9�10 and in private 3�4.’’

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Citation: Int J Qualitative Stud Health Well-being 2015, 10: 26925 - http://dx.doi.org/10.3402/qhw.v10.26925

We end up agreeing on the following assumption:

The attitude I have towards eating is a reflection of

the attitude I have towards myself.

I ask about her eating habits on an ordinary day,

which she describes as follows:

� Breakfast: two pieces of crisp bread and a glass

of milk

� Lunch: salad and a little bit of fish

� When I get home around 6:30, I don’t

have energy for much else than a pizza or a

pita with chicken and a large Pepsi Max. The

‘‘healthy version’’ is that I eat rye bread. And

a bag of candy with a movie is her idea of

peace, happiness, and relaxation.

We are getting close to the end of the session, and

I am very interested in getting concrete about sug-

gestions for behavioural change: ‘‘How about if you

substituted your Pepsi Max with water?’’*‘‘Ah, then I would like it to be sparkling water because of the

fizz,’’ Anna answers in a supportive and motivated

manner. ‘‘But could it be okay with Pepsi Max on

the weekends?’’ she asks. I try to describe, how this

hope of getting Pepsi on the weekends impairs her

ability to fully enjoy the taste of sparkling water* ‘‘So you can make it to the point where you almost

don’t even like Pepsi anymore.’’ ‘‘Actually, Pepsi

sometimes has a weird taste of iron*so you’re right actually. I don’t always like it!’’

Anna suddenly seems very motivated to establish

MORE different changes in her life. We agree on the

following list:

h Only sparkling water instead of Pepsi

h Dark chocolate instead of candy

h Go home earlier from work

h Go for a walk*in the time where I used to stay late at work

Finally, I ask her about how she has experienced the

session and our collaboration. ‘‘The most important

thing for me was the part about taking care of myself.

I really liked when you said it says IDIOT on my

forehead. I need you to push me a little bit,’’ she states.

I am almost a little surprised that she appreciates my

slightly provoking comment in such a prominent way.

I had not expected that.

We agree that we will arrange the next meeting

via email, because Anna does not have her calendar

with her. For this first meeting, she actually came on

her day off.

Reflection on the session

In this section, I would like to see myself as

a practitioner researcher/scientist practitioner, and

thus I would like to reflect upon some of my main

theoretically based positions and strategies, and I

also would like to include some statements from

Anna’s feedback that I received during the very last

session:

In the beginning, I tried to get a picture of Anna’s

life and biography, especially is the parts which were

relevant for her ambition to lose weight. The close

interconnectedness between specific life events and

eating habits became obvious. As the coach I became

the intra-active partner by helping her to understand

herself in a new way. We focused on specific values,

on what was important for her, and how she some-

times struggled with being her. In this collaborative

dialogue the intake of sweets and candy could be

connected to a state of mind where she felt safe, secure,

and trusting. Sweets and food in general had certain

significance in her life, which in the end resulted in

an unhealthy, uncontrollable, and unreflected food

intake. As mentioned earlier, overeating can be ‘‘asso-

ciated with decreased negative affect’’ (Heatherton &

Baumeister, 1991, p. 101) and with avoiding negative

states of mind*the escape theory that explains the avoidance of self-awareness in situations where one’s

own high standards and demanding ideals are under

pressure.

Anna’s life situation and material-discursive prac-

tices around food intake were strongly influenced

by her working life situation. During our coaching

conversation we reached the conclusion that a long

working day had a negative influence on the way Anna

would ‘‘take care of herself ’’*a fact that also had an impact on her food intake. In our final session,

Anna concluded that regular working hours without

overtime help her very much to keep up a healthy

lifestyle and appropriate eating habits. In that sense,

Anna’s decision of working less was a helpful strategy

for her to prevent overeating that arose as part of

a motivated attempt to escape from self-awareness

in situations where her own high standards and

demanding ideals were put under pressure (see the

earlier exposition of the escape theory).

In the last phase of the session, our dialogue

changed from investigative and reflective with a focus

on developmental issues, towards concrete collabora-

tively developed guidelines that aimed to help Anna

reduce her food intake in a way which corresponded

with her wish that lifestyle change should not to

be associated with a permanent state of suffering.

My intention was to negotiate suggestions which

Anna could accept as substitutes for high-calorie

products (e.g., mineral water instead of cola). Anna

and I put focus on collaboratively developed recom-

mendations as a part of most of the following sessions.

What we came forward to was a number of guidelines

that were not based on a position of pure self-control,

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but these guidelines were the result of a longer

reflective process, where Anna became clear about

how her practice in regard to food intake was

influenced by especially her work situation. In that

sense, the guidelines were the result of a process

where they appeared as meaningful to Anna, and

where they were much more than just as a diet

instruction. In our very last session, Anna evaluated

that it was very important to her to realize that

not everything was negotiable. From the beginning,

she felt that I was rather determined in regard to

substituting cola with mineral water. But my in-

vitation to self-reflection and her growing self-

understanding were the most important aspects of

our coaching which made her ready for change.

From the theoretical perspective, the session had

two central phases: (1) in the first and longer part, the

main focus was to give Anna new opportunities for

being an intra-active individual; thus, Anna became

aware of the way her life situation (e.g., long working

hours etc.) had shaped her and, ultimately, her habits

and (2) specific material-discursive practices (e.g.,

buying food, non-cooking, food intake, reading

while eating) had shaped her in a specific way and

put her on a path towards overeating, which even-

tually resulted in overweight.

Milestones of the further process*a reflective analysis

In the following, I present some key themes that

emerged from an analysis of the collected material

(notes by the coach, audio recordings) and which

could thus be identified as key issues and milestones

that helped Anna understand herself differently and

progress in regard to lifestyle changes. The presenta-

tion of these milestones is combined with theoretical

reflections alongside reflections informed by the

intra-active model.

Searching for a new job

In the second session, 1 month after the first, Anna

told me that she had applied for two jobs and has

been invited for interviews at both places. She ex-

perienced this situation as a huge dilemma, especially

in regard to having to say no to possibly one of the two.

‘‘I fell back and drank cola, just to please myself and

to care for myself. I am quite afraid to disappoint

people, and drinking cola is a way for me to cope with

the situation,’’ is how she described her feelings in

the beginning of the session. I got the impression that

she was already quite aware about specific mechan-

isms in regard to her unhealthy eating habits, and

we had a longer conversation about how she could

take care of herself in other ways.

She also told me with pride that she had actually

renounced one of the two job offers, because in the

end she did not like the job, and she was happy

to accept the offer from the other employer. While

remembering the feelings in regard to her work

situation from the first session, I congratulated her

on her great initiative and the big success of taking

responsibility of her own life. ‘‘Now I just have to

stick to my goal that I do not want to work overtime.

I have talked about this in the interview, and they

accepted me on these terms anyway. So, now I can

only hope that they keep this in mind when the

situation comes,’’ were her final thoughts about this

issue.

Concluding this topic, the following can be

stated: Anna had already taken a big step forward by

changing her job situation and by being serious about

specific issues, for example how working overtime

in her current job had had a negative impact on

her lifestyle. From the perspective of the intra-active

model, Anna had a hard time in the first phase of

the process in regard to living up to her high personal

standards (e.g., not disappointing others). Food in-

take became a way for her to calm down and achieve

a sense of safety. Coaching helped her to abandon

some of her old intra-active dialogues: She became

aware of how drinking cola was a surrogate for taking

care of oneself.

Change of attitude towards work

During several sessions, her work situation was

the focus. Already in the first session, Anna became

aware that her perfectionism, or seen from another

angle: her anxiety of not being good enough, of not

living up to her ideals, of losing control, were central

factors in regard to keeping bad eating habits alive.

On many occasions, the pressure she felt at work

led to forms of binge or over eating, where she used

food to calm herself down and first afterwards noticed

what had happened to her. As Heatherton and

Baumeister (1991, p. 10) argued, eating was ‘‘asso-

ciated with decreased negative affect.’’ During several

sessions, we reflected on how Anna could handle

job pressure in a different way. She came to the con-

clusion that working overtime had to be banned,

and we also reflected a lot about how she could

learn to accept herself as a good enough worker by

appreciating her own work effort and by fighting

bad conscience (5th session). I introduced her to

writing a ‘‘scrapbook’’ based on the following task:

Write down three things in the evening which you

succeed with or were happy about during the

day. Through coaching I invited Anna to develop a

‘‘new’’ intra-active individual by helping her to

understand herself in a new way, thus supporting

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her in developing new material-discursive practices

that could help her to view and ultimately handle

specific work situations in a new way. Furthermore,

by introducing a ‘‘scrapbook,’’ I helped her appreciate

herself more and become aware that she actually

was not far from living up to her ideals.

Being mindful

We worked quite a bit on being mindful. During

the first session, Anna told me about her habits.

Preparing food had no high status in her life. Often,

when coming home from work late, she just bought

a pizza or other types of fast food from a corner

shop, plus a big bottle of cola, and while eating she

used to watch TV or do further work or reading on

her computer. Even when she did her own cooking,

she did not seriously value her own effort. Also here,

she combined eating with reading or watching TV.

I made an ‘‘irreverent’’ 2

statement: ‘‘So, the dining

Anna does not give much respect to the cooking

Anna!’’ We talked about possible consequences (e.g.,

the amount of food she might eat), it could have

been that she was not thinking about or, to put it

even better, fully sensing her dining. I introduced

her to the mindfulness exercise where you eat a raisin

very slowly and mindfully (www.staroversky.com/

blog/mindfulness-exercise-eating-a-raisin-mindfully,

retrieved 20 November 2014). The exercise was an

eye-opener.

We developed an agenda for good habits: No TV

while eating, be attentive when eating, enjoy the

nuances of your food, be in the here and now of the

situation, enjoy the pleasure of your own company* and slowly Anna changed her attitude and habits

on the basis of new and positive experiences. She felt

that she was taking herself much more seriously and

taking better care of herself.

Inspired by the intra-active model, developing

these new habits became the basis for shaping a new

understanding about her material-discursive prac-

tices around eating. These new practices were also

the basis for understanding and shaping herself in

a new way*somehow becoming a different person, because the meaning associated with eating appeared

to unfold in a new way.

Making plans*establishing alternatives

As in the end of the first session, we frequently made

plans that helped Anna focus on specific aspects of

lifestyle change, for example, Monday to Friday: no

warm food in the evening, only one to two slices of

bread with salad and one piece of fruit, walk to and

from work twice a week, practice the raisin exercise

every evening, and take a long walk during the

weekend. She decided to work on a painting on the

topic ‘‘my wishful state, my best possible future,’’

which we talked about in the following session.

These plans were like a contract between us. They

helped keep her on track. We celebrated her suc-

cesses. And if there were objectives she struggled

with, we reflected about her challenges.

We developed alternatives together, for example,

breathing like in yoga, especially when she experi-

enced a situation as stressful; baking and eating

stone-age bread (only with nuts, sesame, etc.*no flour); and inviting her sister to be a buddy to help

keep her on track. After 4 months, Anna started to

jog or walk every day. At this time, she also decided

to begin with the 5:2 diet (Mosley & Spencer, 2013),

which her sister (with no weight problems) already

practiced.

Here, the focus was on her material-discursive

practices, which also shape the individual’s develop-

ment. By changing these practices, the individual

gets a chance to act and, somehow, to be different.

A change of practices in regard to how to eat and

live one’s life has an impact on the way a person

is able to see herself. As our sessions progressed,

Anna felt increasingly ready for the changes that

were necessary for her to succeed in ‘‘reaching her

goals,’’ which basically revolved around developing

new practices that were established as meaningful

in regard to her life and the life she wished to

construct. Gradually, we developed a working rela-

tionship, where I as the coach became a fellow human

being (Stelter, 2014) and an active supporter of the

change process.

It is not a cure*it is my life!

This sentence was presented by Anna during the last

session, where we were looking back and evaluating

the course of our working relationship. Changes

are not just a cognitive decision; they have to make

sense in the actual world of the client. Changes have

to grow based on the reflective process about the lived

challenges of the participant. Anna has learned that

her binge or over eating was actually closely related

to insecurity, loss of control, lack of self-confidence,

or stressful life events. During one of our later

sessions, she remembered a situation when she was

little and her father*who was divorced from her mother*asked her to cook for both of them. Although her father did not have bad intentions,

Anna felt terribly pressured by this responsibility.

She wanted to do her best but felt that she could

hardly handle the pressure. Remembering (Stelter,

2014; White, 2007) this early event and articulating

her feelings suddenly made her ready to understand

a lot of later experiences in her life; events that she

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had reflected on since the first of our sessions. This

story really made her ready to see herself in a new

light. On the basis of whole-life perspective, weight

loss is not just a matter of diet, physical activity,

and eating habits. Bad habits have their story, their

good reason. When Anna learned to understand her

story, the path of development and change was made

possible.

In conclusion, this episode and the whole course

of sessions are to be examined in light of the intra-

active model that was presented as the theoretical

framework. Generating meaning in a new way and

through the collaborative process between Anna and

the coach was regenerated in and through the intra-

active dialogue with Anna who was able to reflect on

herself and her practices in a new way. In collabora-

tion with the coach, Anna was a narrator of specific

events and life situations. In this course of coach-

ing session, the intra-active dialogue was supported

by a collaborative partner, the coach. Meaning was

shaped through reflecting, re-telling, and remember-

ing of different life situations and specific practices

that seemed understandable but inappropriate. This

process of achieving a new understanding of oneself

and of having a partner in one’s intra-active dialogue

can be seen as the very foundation of change. The

goals that were formulated in specific situations

needed to be anchored in a new understanding of

what was seen as meaningful and, at the same time,

anchored in specific values that were important to

the individual and which could be translated into

action through specific material-discursive practices.

Anna’s final reflection on the coaching process

When I, as the author, decided*with informed consent of Anna*to write this article, I also asked Anna to write an honest final reflection about her

perspective to our course of coaching sessions and

the impact they had on her. This is what I received

from her.

Goal and results

After around a year and a half of coaching, I have

become 12 kg lighter. It is a great relief and that’s

why I choose to use the term ‘‘becoming lighter’’

instead of ‘‘losing weight.’’

My original goal when I first started was*as far as I remember*to lose 20 kg or a little more than that. I haven’t reached that goal yet, but my life has

changed in so many other ways, it feels like the goal

has been reached. The goal has changed during

the coaching process. It quickly became clear to me

that it wasn’t going to be a diet where I, after my

goal was reached, put all the weight on again and

maybe even more. That has happened before. This

time it was going to be a lasting change in lifestyle.

That point has been quite central in the process, as

the goal is more about having a normal relationship

with food than losing weight. But that also means

that the weight loss hasn’t gone as quickly as if I had

been on a diet. A challenge in the process has been* and will most certainly continue to be*finding the balance between cutting back on junk food and

sweets and also finding a level that is possible to

adhere to for the rest of my life. An important point

that became clear during the coaching was that it

is not about losing something or restricting myself

from the things I like. It is more about the amount

and trying to come up with good and delicious

alternatives, so I don’t feel like life is tough and

unfair, because I always have to say no to the things

I want. The coach made it clear to me that it is all

about doing something good for myself.

Added bonuses

Other goals I have reached in the process are:

becoming healthier, also in the long run, more mind-

fulness in my daily life, not only when I eat. One of

my underlying goals was to start exercising again* running and playing tennis. I have started running

again and besides, I have found joy in walking to and

from work*a couple of hours every day. The most important thing has been the feeling

of coming out of a deep dark hole. I have gone from

having an inner voice telling me every day that

I must eat sweets or the like, to feeling like I have a

choice*I can choose to eat it or I can choose not to and do it another day. That is the greatest relief.

Process and theme

How has this happened then? Conversations with the

coach about habits and automatisms, presence and

being mindful, my childhood, and about my sensing,

when I eat*those have been the key ingredients to the success. The fact that we have spoken on the

basis of my entire life*especially my work life*and the fact that I have had the opportunity to express

myself regarding the pressure I feel in relation to my

work life has made a great difference. Along the way,

between the sessions, I also gained insights from the

past, which I had repressed, which have had a say

in why I react as I do to demands, expectations,

and perfectionism. This development has led to me

being more attentive and not taking everything so

seriously. Actually, you could say that I am now in

a process, where I am practicing making mistakes

and not complaining about it.

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The coach has been inspiring me, listening to me,

and challenging me*challenging me especially by questioning my understanding of how things are

tied together*for example, that it is not a must to overeat because you feel that you are under pressure.

The coach has also brought concrete suggestions

to the table*for example, the good tip about trying the 5:2 diet, which turned out to fit well with my

temperament, and is in line with the idea of not

restricting yourself from the things you enjoy, but

enjoying less of them.

An important quality of the coach has been setting

firm requirements for what I could and couldn’t

do. For example, I wasn’t allowed to drink cola.

I suggested that it could be okay on weekends, but

that was a no go. And it turned out that I quickly

found joy in drinking sparkling water instead. Con-

sidering who I am as a person, it has been a plus

to have pretty firm orders. Of course I could do as

I pleased, but it was clear to me that if I was serious

about the coaching I had to ‘‘obey orders.’’ When I

first began with the coach, I drank 1½ L of cola every

day. Today I drink it on special occasions, and weeks

can go by where I don’t drink it.

The coach as a role model

It may sound as if it has been easy*and it both has and hasn’t been. At times I have been surprised that

it isn’t harder, but there have also been times, where

it has taken a lot of will power not to slip into ‘‘today

it’s okay to eat some sweets.’’ When having those

thoughts, it has surprised me what role a coach plays.

In these situations, the coach pops up in my head as

a reminder. It is, of course, the feeling of having a

responsibility toward the coach (and myself of course,

but for me it is played out through the coach).

The coach as a person has thus been a point of

attention and been an inspiration in regard to keeping

the deals we have made. The feeling that the coach

has also given a part of himself*he can be under a similar pressure, but that doesn’t mean he eats

unhealthy things*has also been an inspiration.

Timing

In regard to the relief I have achieved*‘‘getting out of the dark hole’’*I have afterwards thought about the timing of the process. Would I have achieved the

same results if I had gone to see the coach sooner?

Could I have avoided gaining the last five kilos? My

answer is no, because the process has made it clear

to me that it is also very much about being ready

for it. Without my commitment and without me

being ready to take action it won’t succeed*even a motivating coach can’t change that.

The future

Naturally, I wish for it to pass quickly*meaning that I quickly will get even lighter and get rid of the

last 10�12 kilos. But if I can do it the way I have just done it*lose it over the course of a year and a half, then that would definitely be preferred. Because it

feels good that it is happening on the basis of me

being aware of having a normal relationship with my

food and what I consume.

Conclusions

In this short section, I highlight a couple of conclu-

sions that stand out from both my analysis of the

sessions and Anna’s evaluating reflections:

� Health belief is a pure basis for change: Perceived

seriousness, perceived susceptibility to specific

health and lifestyle issues, might lead to a

growing awareness of health issues, but it did

not help Anna understand herself and the

complexity of her life situation as the basis for

changing her lifestyle.

� Being ready for change: Anna stated that

the time was ripe for her to change. Bohart

and Talmann (2010) highlighted the client

(in psychotherapy) as the central agent in the

change process. With reference to different

studies and authors, they see the client as

the most important determinant of outcome.

This can be assumed to also apply to coaching.

Clients are not passive recipients in the dialo-

gue; their willingness, their active involvement,

and their way of making meaning of their life is

pivotal for the progress and the effect of the

intervention. In our last session, Anna empha-

sized that it is hard work to keep her ambitions

alive and to continue to strive towards her goal.

� Perceived support and encouragement from the

social environment and from the coach are

fundamental for the client’s willingness and

ability to develop further and continue on the

desired path. From this perspective, Anna’s

sister, as a supportive buddy, had a major

influence on keeping Anna on the right track.

They shared something important in their

lives* Anna could phone her sister when things got hard (see also Weiner, 1998). The

change in Anna’s working environment (i.e., no

overtime work), has been another key element

which supported her weight loss ambitions.

� Anna mentioned the commitment of the coach

(i.e., the determination to get her to drink

mineral water instead of cola) as an important

element for her development. This coach

commitment was acknowledged by her as

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one of the central elements which kept her

going. The collaborative perspective, also in

regard to what worked well for her during

the sessions (Miller, Duncan, Sorrell, Brown,

& Chalk, 2006), was the key aspect of a

fruitful and generative dialogue.

Acknowledgements

I thank Anna for her cooperation, not only during

our sessions, but also in regard to supporting the

article. I wish her all the best for the future.

Conflict of interest and funding

The authors have not received any funding or

benefits from industry or elsewhere to conduct this

study.

Notes

1. The decision was made on the basis of an invitation by the

guest editors of this issue, and after the first review of the

suggestion of the topic and abstract provided by the author.

The client of the study has given full consent to be the case of

this study. On the basis of Danish law, an ethical approval for a

social science study like this is not needed. Ethical committees

simply do not treat social science research applications.

2. This term is used in systemic therapy and coaching (Cecchin,

Lane, & Ray, 1993).

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