Ruth Q. Wolever, PhD, NBC-HWC
The growing need to prevent and improve the lifestyle behaviors that drive chronic disease has brought about new roles in health care including that of health and wellness coaching (HWC). As use of terms such as “health coach” has spread, so too has the need to clarify the definition of “coaching.” Health professionals routinely “educate and advise” patients, according to their scope of practice. But to coach does not mean “to educate and advise,” nor does it mean counsel, direct, assess, diagnose or treat. This article clarifies what HWC actually is and provides health psychologists with information about emerging self-regulation in the field of HWC. The article also distinguishes HWC from health psychology and invites health psychologists to use their deep expertise to advance this emerging field.
Two large endeavors in the recent past have defined HWC. The first endeavor was a response to multiple calls in the literature for a clear role definition of HWC. A PRISMA-guided systematic review evaluated 284 articles to clarify the operational definition of HWC as seen in the peer-reviewed literature. The following definition emerged:
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. The coach is a healthcare professional trained in behavior change theory, motivational strategies, and communication techniques, which are used to assist patients to develop intrinsic motivation and obtain skills to create sustainable change for improved health and well- being. (Wolever, Simmons, Sforzo, et al., 2013).
Fewer than a third of the reviewed studies described the actual coaching methods used, hindering a full evaluation of the effectiveness or contribution of specific methods, and replication in other studies. Hence, to move the field forward, the specific tasks undertaken in HWC still needed to be better defined and consistently applied in order to inform and protect the public and support more stringent research methodology in future studies.
The second endeavor was to delineate and validate HWC using best-practices on credentialing, per the Institute of Credentialing Excellence and the American Psychological Association. In 2010, a collaborative effort known then as the National Consortium for Credentialing Health and Wellness Coaches (NCCHWC) established a clear and consistent definition of HWC with uniform practice and training standards. The 501(c)(3) non-profit NCCHWC ran a Job Task Analysis (JTA) and validated the findings (a total of 21 tasks) in a large survey of individuals practicing HWC. Following the validation of the job role, the needed training curricula – entry-level skills and knowledge – could be defined.
The work of this non-profit garnered the attention of the National Board of Medical Examiners® (NBME®) who was exploring trends in health care. The NBME® serves the health of the public through state-of-the-art assessment of health professionals and is best known for its role in developing and managing the United States Medical Licensing Examination® (USMLE®).
NCCHWC and NBME began working together in 2016 to launch a national board certification for health and wellness coaching. Subject matter experts articulated the skills and knowledge needed to carry out the tasks as specified in the JTA and formed the blueprint for the exam with clearly-defined content. The International Consortium for Health and Wellness Coaching, being renamed the National Board for Health and Wellness Coaching, is a newly formed 501(c)(6) nonprofit that offers the exam once a year at over 300 proctored sites.
Approved HWC training programs have the responsibility for ensuring that certification examination candidates adequately demonstrate the practical skills needed to perform HWC at a minimally competent level. Since the initial exam offered in 2017, roughly 2000 National-Board Certified Health and Wellness Coaches (NBC-HWCs) have passed and qualified for this credential.
Most health psychologists would agree that the job tasks for the HWC fall under the scope of practice of health psychology and represent a subset of what health psychologists do (e.g., show empathy, work with the client to establish goals that will lead to the client’s vision, elicit the client’s perspective, explore broader perspectives, engage client in problem-solving, etc.). However, most of the tasks health psychologists do, are not encompassed by coaching. Importantly, the HWC does not diagnose, advise or treat. What well-trained coaches do extraordinarily well, that most psychologists (even health psychologists) are not trained to do, is invite the client to imagine a better situation through a visualization exercise. Coaches do not tell them what to do, but rather elicit from the client what the clients believe they should do based on their desired outcomes.
While coaches and psychologists both “follow” the client, they do it differently. The psychologist takes cues from the client to assess what is wrong–what skill is missing, what behavior is off, or what habitual thought or perception is causing problems. Then, psychologists work to help the client obtain that missing skill, correct the behavior, think differently or adjust the perception. Coaches, on the other hand, don’t have a pre-determined job. They go where the client wants to go – whether the coach would make the same choice as the client is irrelevant, because the coach holds a mindset of curiosity and encouragement without directing what is next. Coaches are experts in a particular process of change, in how to facilitate – not direct or lead – the client through identification of the goals they want to achieve, followed by a series of small steps as experiments to figure out the best way to achieve them. It may seem a really subtle distinction; however, it has huge implications for practice. When listening to the client, the psychologist is comparing the information against years of training and information to assess the situation and create a treatment plan. Coaches have the client self-assess and create a plan to attain their self-determined goals. Coaches are not assessing and they are not treating. That said, coaching is an incredibly powerful process that builds self-identified goals, self-efficacy, and reinforces self-learning. In many ways, coaches are Socratic teachers who don’t have the answers, but have a well-formed ability to hold the space of exploration with curiosity, kindness and non-judgment, supporting the client as they learn from the prior week’s experiments and plan out the next small step to undertake.
I had been practicing as a clinical health psychologist for 8 year before I also started health coaching. It took me about 4 years of practicing coaching to fully understand what the difference between coaching and health psychology is, and I’m hoping to save you the same struggle. It took so long because I was using the coaching skills (as I’d learned them in a psychology context across the course of my health psychology training) but I was not fully operating from a coaching paradigm. I had been trained to assess what was going on with the client and to create a treatment plan to address the problem. I’d find myself internally asking, “what skills is the client missing,” “what perceptual distortion needed to be corrected,” “what behavioral sequence needs to be built,” “what is driving the emotional dysregulation,” and so on. I could not stay fully client-centric because I was trained to identify and assess the problem, then craft the solution. I considered myself progressive because I co-crafted the solution, ensuring client buy-in. So, when I started coaching, it took me quite a while to stop the expert role of assessing, and just see where the client took us.
A daunting task lies ahead with 6 in 10 United States adults diagnosed with a lifestyle-driven chronic disease and 4 in 10 having two or more chronic diseases. It’s abundantly clear that health psychologists and health coaches are both needed, and both approaches have much to offer. In particular, health psychologists can help ensure the spread of a consistent role delineation for HWC, that focuses on a clear scope of practice. Research is also needed to further explore the effectiveness of coaching, identify the key drivers of behavior change, clarify when coaching is not appropriate, and demonstrate which interventions need the expertise of the health psychologist. Psychologists can help to move the needle forward by elucidating these empirical unknowns.
Wolever, R. Q., Simmons, L. A., Sforzo, G. A., Dill, D., Kaye, M., Bechard, E. M., … Yang, N. (2013). A Systematic Review of the Literature on Health and Wellness Coaching: Defining a Key Behavioral Intervention in Healthcare. Global Advances in Health and Medicine, 38–57. https://doi.org/10.7453/gahmj.2013.042