The Ambivalent Shift Worker
Marcus, 47, supervises a warehouse crew on rotating shifts (two weeks days, two weeks nights) and was referred by his physician after an A1c of 6.1%. At intake he says, 'My doctor told me to change everything - diet, exercise, sleep. Honestly, I don't think I can.' He rates the importance of changing at 9/10 and his confidence at 3/10. He has quit two commercial weight-loss programs inside six weeks and describes both as 'all-or-nothing.' He mentions, almost in passing, that his father lost a foot to diabetes. He asks you to 'just tell me what to do' and says he can give you 20 minutes a day, three days a week, no more.
1. Given importance at 9/10 and confidence at 3/10, where do you aim your first several sessions, and what do you deliberately avoid?
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Target confidence, not importance. Importance is already high; adding more education about diabetes risk or more warnings pushes on a door that is already open and tends to raise resistance and shame rather than behavior.
- Ask what makes confidence a 3 rather than a 0 - the answer usually contains usable resources ('I quit both programs, but I did walk every day for two weeks when I was on days').
- Evoke past success and exceptions to the pattern; ask how he managed the two weeks that worked.
- Shrink the change until confidence rises. Twenty minutes, three days a week is enough to start; pick one behavior tied to the shift rotation rather than 'change everything.'
- Handle the father's amputation carefully. It raises importance but can also fuel avoidance ('that's not going to be me, so I don't want to think about it'). Reflect what he said; do not amplify fear.
- Re-rate confidence before the session ends. If it hasn't moved, make the step smaller - do not argue harder.
- Frame the plan around the two-week rotation, not a fixed routine he cannot keep.
2. He says, 'Just tell me what to do - you're the expert.' How do you respond without damaging the alliance?
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Reflect the wish for direction and honor it while keeping ownership with him.
- 'You want me to take the guesswork out of this - that's fair, and I will. I also want a plan you'd actually do at 6 a.m. after a night shift.'
- Give real structure: a menu of two or three concrete options per target behavior, say which you would pick and why, then let him choose.
- Explain the mechanism honestly: adherence comes from plans the client helped shape. A plan imposed by an expert is the plan he quit twice before.
- End with one specific action, a defined cue, and a confidence check of at least 7/10.
- Avoid the two failure modes: refusing to give direction (feels useless, client leaves) and taking full ownership (he becomes a passenger and the first bad week ends the program).
3. At week 4 he misses two sessions and reports a 'bad week.' What do you do, and what would be a mistake?
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- Normalize it: a missed week inside a rotating shift schedule is data, not a verdict on him or the plan.
- Run a short functional analysis: what was different (night rotation? kids? sleep?), what he did instead, what he felt right before skipping.
- Look for the all-or-nothing rule he named at intake: 'I missed Tuesday, so the week was gone.' Name it and counter it with a minimum-dose plan ('ten minutes counts').
- Re-contract with shift-specific versions of the plan for day weeks and night weeks, a defined minimum, and the re-entry session already booked.
- Re-check confidence; if it dropped, shrink scope again.
- Mistake to avoid: adding pressure, more sessions, or visible disappointment. Those raise shame and predict dropout.
- Document the lapse, the trigger, and the revised plan.