On Clinician Engagement and Counseling

Steven Jonas

INTRODUCTION: THE ESSENTIALS OF EXERCISE COUNSELING

The process known as exercise counseling is the central element in helping your patients to become regular exercisers and in providing them with an exercise prescription that will work for them. Many prescriptions that we clinicians provide—for medications, for various diagnostic procedures, and for various forms of non—medication therapy—are delivered from us to our patients. That is, they are “external” to the patient. Regular exercise, on the other hand, is an activity—a “therapy” if you will—that can be termed an “internal form of therapy,” for it requires a major element of patient self-management. It is an intervention that your patient has to undertake himself or herself on an ongoing basis.

To effectively provide prescriptions for medications and other external forms of therapy, the highest levels of compliance are achieved when you are able to form a partnership with your patient. Yet doing so in these cases is not essential. Many patients willingly accept the clinician’s direction and comply without entering into a partnership. With the exercise prescription, however—because its implementation requires an ongoing, active role for the patient—it is essential for effective counseling that a partnership be formed. You will help your patient get started, and you will provide advice as he or she goes along, on a when, as, and if basis. But, as noted, the long-term management in this case is primarily self-management. The patient will be in control. To help them take it and use it, you must be able work with them in a cooperative, rather than a totally directive, role.

Further differentiating regular exercise from most other health-promoting, disease-preventing, and disease treatment interventions is the fact that it takes time on an ongoing basis, time that was spent, before the person became a regular exerciser, doing something else. For as long one does it, it takes up time not formerly spent on it, but rather spent on other activities. Only a few other interventions—such as staying in an Alcoholics Anonymous or similar program for recovering alcoholics and other substance abusers or being on kidney dialysis—are similar. In contrast, consider the behavior of healthy eating.
Maintaining one’s nutrition requires food shopping, food preparation, and eating. If a patient is currently practicing unhealthy eating habits and decides to convert to healthy ones, some time will be required to learn them. Some time may be spent in a weight-loss program, for example. However, eventually, if and when the nutritional goals the patient set are achieved, shopping/preparation/ eating will take just about the same amount of time as before, perhaps even less. Thus, effective counseling for regular exercise has some special characteristics.

Foremost, as noted, to effectively implement the exercise prescription, the counseling process must take on the nature of a partnership. It cannot be a paternal/maternalistic relationship between clinician and patient. Especially with regular exercise, the “me doctor (or other clinician)/you patient,” “do what I say to do [with perhaps a please attached]” will not work. Even though in the approach of Exercise is Medicine™ it comes in the form of a prescription, you are asking your patients, suggesting to them to do something that: a) will require the expenditure of time on regular basis, as noted; b) may well be totally foreign to them in terms of anything they have previously done in their lives; c) may at the beginning result in some mild pain (that is mild, not moderate-to-severe, if with your help they start off in the right way); d) may eventually require the expenditure of funds for anything from equipment to a gym membership; and e) in the minds of some will make them appear to be “different,” not necessarily in a good way, to friends, family, and co-workers, as in the totally antihealth, “exercise nut” label.

Therefore, it is important to engage in interactive, rather than didactic, communication. You must be able to, or learn how to, exchange information with your patients rather than just deliver it to them. To be most effective, you will have to empower your patients to take control of the process, to learn for themselves, and, most important—as we will see in the following text and then throughout the book—to engage actively in the multiple steps in the health-promoting/positive-behavior-change process.

Let’s begin with goal-setting. As a regional triathlon coaching organization, Tri-Hard Sports Conditioning, has said (1):

There is much more to [regular exercise] than the physical aspects of conditioning. Training your mind is just as important and doing so begins with goal-setting. When a new athlete approaches us about coaching, the first thing we ask them is to tell us in detail about their goals…. When they write down their goals, they are forced to look at them and [consider them carefully]. This is important because … knowing what their goals are what motivates them to live well as they pursue [the achievement of them].

You will help your patients raise questions to which they can find the answers themselves, often in resources that you will either give them or direct them to. Actively finding those answers will produce much more effective learning than if you simply provide it for them directly. Of course you will provide certain
answers of a didactic type: what is a good training regimen to get started with. But in most cases you will be much more effective if you help your patients find other kinds of answers for themselves, e.g., what defines success for them.

Effective counseling for the regular exercise prescription requires that you be able to help your patients to mobilize their motivation. Chapters 4, 5, and 6

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