Wednesday, August 14, 2013

 How to Get People to Change for Better Health

GLOBAL MEDICINE NEWS

For Immediate Release

By Dr. Meg Jordan

SAN FRANCISCO ) --- Although health coaches may be the newest actors among health care professional groups, they are burdened with the most significant task–helping people change and grow. But having entered their camp for ethnographic study, I find it is a task they accept with relentless enthusiasm. As one coach trainer told me, "We're just products of our product, facilitating the attainment of optimal health and happiness. Health coaching is not a job—it's a way of life. You've got to walk the talk."

It's no small undertaking to position oneself as a "lifestyle turnaround expert;" however, a key group of health coaches, coach educators and health care allies have recently formed a new organization to legitimize this emerging discipline, and staked out their unique professional territory.

In September 2009, over 50 individuals, identified as key stakeholders, were invited to meet in Boston by two organizers—one from academia, one from a private coach training company. At this first Health Coaching Summit, the organizers secured sufficient "buy in" from over 80 health-related organizations to launch a national consortium to define the profession and set educational standards. Their long-term goals were to "secure a place at the health care table;" and "issue one certification exam for all health coaches;" however, what these same individuals did not entirely foresee was the resistance that they would confront from seemingly aligned groups, such as holistic nurses and health educators.

As a participant-observer on their national leadership team, I've been in awe of the precise, rhetorically powerful, and straightforward process by which they optimistically pursue their time-lined goals. One would have to be optimistic to strive for uniformity and consensus among dozens of healthy egos with pedigreed lineages (social scientists, psychologists, MDs, RNs, health educators, public health officials, health agency officials) in fields that rarely pulled together for the good of all.

Two years later, the newly coined National Consortium for Credentialing Health & Wellness Coaches (NCCHWC) is comprised of health coaches, wellness coaches (yes, they appear to be different at this stage), academic educators of health coaching, owners of private coach training businesses, and leaders from an invitation-only list of health-related organizations. The consortium defines their emerging discipline as the process of applying theoretically grounded, evidence-based approaches for achieving lifestyle improvement, discarding unhealthful habits, and adopting new daily actions and a positive outlook to live the happiest, healthiest lives possible.

ESSENTIAL COMPONENTS OF HEALTH COACHING

A central tenet of health coaches is that happiness and wellness are inextricably linked. As one coach from the UK said, "Our unhealthy lifestyles are responsible for mounting fatigue, physical toxicity, depression, and spiritual malaise. Coaching establishes a supportive alliance in which the client can tap into inner strengths and external resources to achieve health and vitality, and ultimately, happiness and fulfillment."

While the pragmatic side of health coaching may highlight improvements in diet, exercise and stress reduction, there are integrative models that include numerous skill development exercises to increase the ratio of positive to negative emotions, enhanced social connection and belonging, along with fruitful engagement with a sense of purpose and meaning. The Authentic Happiness Coaching model (Seligman et al 2005) draws from scientific studies that reveal greater life satisfaction is largely a learned art. Process-oriented coaches hold conversations in which clients identify their strengths and values and learn to anchor them in their imaginations, remembering them when challenges and difficulties arise.

Many coach training programs emphasize the building of a safe and trusting relationship, similar to psychotherapy, whereby the client is willing to acknowledge undesirable habits or entrenched behavioral patterns which have derailed well-intentioned efforts in the past. "We come to coaching because we haven't been able to achieve something on our own, and recognize that we need the perspective of someone who can see beyond the box we find ourselves in."

While there is a reliance on intellectual processing, most health coaches focus on integrative or humanistic approaches, in which coaches work with visual tools (the Wellness Wheel) which help the client reflect on their experiences in several domains (relationship, occupation, physical, environment, work/career, financial situations, community networks, fitness, nutrition, intimacy, etc.).

The more advanced programs include aspects of adult learning theory, Appreciative Inquiry, Non-Violent Communication, self-efficacy model, transformative learning and Motivational Interviewing ®, which is borrowed from substance abuse counseling. The Tanstheoretical Model (Prochaska and DiCLemente 1984) features prominently as coaches facilitate stages of behavior change which sometimes overlap or cycle back.

Traditional goal-setting techniques are the mother lode of all coaching programs, whether life purpose coaching or health coaching, since the essential process is results-oriented, with concrete strategies rooted in action and achievement. "We're not interested in the "why" but in the "how," explains a psychologist recognized as the "first wellness coach." The acronym SMART goals is emblematic of the coaching process: smart, measureable, achievable, realistic, and time-framed.

THE CALL TO ORGANIZE—AND THE PUSH BACK

As they struggle for inclusion, respect and the golden ring of reimbursement, health coaches occupy the lowest rung in the health care field that is underscored by strict medical ascendancy. It is obvious that turf protection and competition for the shrinking reimbursement disbursements lay the ground for intense scope of practice debates to come. There is one ray of hope, however, since the recognition that an ailing sick care system can no longer afford not to shift the focus to prevention and personal responsibility for one's health behaviors. The Affordable Care Act may hold some promise for health coaches, with its call for innovative community initiatives for preventive health. "We are going to need legions of first-tier lay health professionals to address the massive challenge in lifestyle turn-around for millions," said an MD at an Institute of Medicine conference.

Who determines what that right "lifestyle choice" is? Not everyone is in agreement about the pathways for improving health. One well known physician, famous through appearances on "Oprah," objected at the Boston Summit, "I'd have a real problem having any health coach tell my patients what to do…how do I know they're giving them the right advice?" Some coaches might have bizarre notions of what constitutes a health diet. To which the coach trainers in the room, responded with, "Coaching is not about giving advice. It's about facilitating and evoking change from within –all to improve health and well-being."

And with that comment, a heated debate was launched that is still ongoing two years later. How much expert knowledge does a health coach need if the coach is simply facilitating clients to come to their own decisions, discover their own resources and reach for additional information on their own? Should health coaches be experts in nutrition, weight management, exercise physiology, behavioral psychology, and the psychophysiology of stress? The coach purists insist that highly competent coaches can coach on any subject at all—they never need to be experts in the topic at hand.

"But we're health coaches, not just business coaches or life coaches. The public expects us to have expert knowledge," agreed educators from three universities with coaching programs along with leaders from one of the oldest private training program, all members of the Leadership Team of the National Consortium. They insisted the health coaches must know the essentials of healthful food choices.

"What do you say when your client proposes to drop 20 pounds to by eating nothing but grapefruits for two weeks? You can't just sit idly by—you have to put aside your coaching role, ask permission to be a consultant for a moment, and steer the client back to sound nutritional principles." But how much nutrition education is required? Do you need a full course in macro and micronutrients or nutrition for weight management? And will you be doing actual nutritional counseling? All these questions let loose a firestorm of objections and contested issues, echoing the current debate between CCNs (certified clinical nutritionists) and RDs (registered dieticians) on who gets to use the label nutritionist?

And who will get to call themselves health coaches? As the profession comes of age, the training in positive psychology and resilience will be put to the test. Next steps for the consortium members include securing a job task analysis to define what real-world health coaches actually do with their clients, and then articulating the knowledge and skills necessary to perform such tasks, and finally, proposing minimum educational standards required to learn that knowledge base and demonstrate those skills. Whether one certification exam will unfold for this nascent profession of health coaches is yet to be decided.

A great opportunity exists for medical anthropologists to reflect a deeper understanding of socio-cultural-political context when it comes to health and happiness, and elicit from the coaching community a commitment to reduce health disparities. So far, they have placed the onus for health improvement squarely on the shoulders of the individual, when in fact, no great strides in health or well-being are made in a solitary manner. The quest for health and happiness is always a two-step, with personal responsibility cradled with a cauldron of social support.

-- - - - - - - - - - - -

Meg Jordan is a medical anthropologist, RN, professor and department chair of Integrative Health at the California Institute of Integral Studies. She is a member of the National Consortium for Credentialing Health & Wellness Coaches and recipient of a grant to bring wellness coaching to residents in subsidized housing.