A new domain of professional coaching is emerging. The domain is health. The challenges to be found in this domain are many—and quite diverse. In seeking to identify coaching opportunities in the domain of health, we turn to a metaphor offered by Dr. Camara Phyllis Jones of the American Public Health Organization. Her provocative metaphor sets the stage for what I believe is the future of health-based coaching. Dr. Jones describes the situation where a cluster of people stand on the edge of a cliff. Some of the people fall off the cliff; fortunately, there are ambulances waiting at the bottom of the cliff to pick up the hurt people and take them to a hospital for treatment. This is Tier One (Treatment). Alternatively, nets and trampolines are placed half way down the cliff which will catch the people as they fall off the cliff. This is Tier Two (Amelioration). A third alternative is for a fence to be built at the top of the cliff which prevents people from falling off the cliff. This Third Tier (First Order Prevention) leads to fewer casualties. Jones suggests that there is a Fourth Tier: people can be encouraged to move away from the edge of cliff. This Second Order Prevention strategy eliminates the need for a fence, net or ambulance. Practitioners of health-based coaching can engage in one or more of the coaching strategies associated with each of these four tiers.
Tier One: Treatment
At Tier One, the Health-Based Coach, in essence, helps an “injured” or “ill” person (who fell to the bottom of a cliff) with identifying and articulating the nature of the injury/illness, while identifying and contacting appropriate treatment professionals. A health-based coach usually cannot provide direct treatment strategies (unless a licensed professional), but can provide valuable advice, information and assistance to someone who is injured or (more frequently) in need of medical health for a lingering disease. The health-based coach can also offer assistance (Tier One, strategies) that reduces the impact of injury or illness (such as identifying appropriate and competent health care assistance—be it a home-care professional or rehabilitation facility).
Tier One coaching is especially valuable if the coaching client is elderly, traumatized: or afraid of “medicine”, The coach can be of significant help to her client if the client comes from another culture/society and is unfamiliar with health care practices in the “new” culture/society, If one’s client is without family or social support (living in isolation) the health-based coach can fill in as a caring and assisting support service.
A colleague of mine provides this type of coaching for several elder clients who are without family or consistent community support. My colleague has often made herself available to her clients when then have fallen, suffered a minor stroke, or went to the hospital with a life-threatening fever (occurrences that are all too common among the elderly). She provides “hands-on” assistance, helping her client check in at the physician’s office or hospital. She also sits in on meetings of her clients with the physician. One of her clients recently held her hand and told her (with considerable emotion) that he believes he would not be alive right now without her caring support. While many elderly men and women need full-time health care assistance, others only need to know that a Tier One health-based coach is available when needed.
Tier Two: Amelioration
In keeping with the Cliff metaphor, the Tier Two Health-based Coach encourages her client (who has been “saved” by the net) to seek and maintain health care practices that are of value in their recovery and in their avoidance of further complications. Frequently, with Tier Two coaching, the coaching client has had a “wake up” call – having suffered a stroke, having been given a startling medical diagnosis regarding diabetes or a pre-cancerous condition, or having just recovered from a broken limb.
“What do I do to avoid further injury or illness?” The health-based coach can help her client answer this question in three ways: (1) identify appropriate ways to pose this question to their health-care provider, (2) suggest articles, books and reports that the client might read for their “self-help”, and (3) ask client challenging and generative questions regarding their own health habits (what led them to fall from the cliff) and potential sources of personal as well as family and community sources of support for (and resistance to) their new health habits. This third mode of coaching assistance (asking generative questions) is often of greatest value–and most often missing in a client’s life.
Tier Two health-based coaching is especially valuable with regard to medication compliance, identification of healthy habits (nutrition, exercise, sleep) and identification of potential household hazards. Health-based coaches can often offer their clients tools and strategies for the effective management of stress. They can also help their clients assess environmental conditions that are conducive or detrimental to health (an assessment that sadly is becoming increasingly important in many communities throughout the world).
I have worked very closely with a colleague for many years who has recently taken on the job of providing Tier Two coaching. He recently recovered himself from a stroke and is involved in his own ongoing rehabilitation (while also changing many of his health habits). While spending time with other stroke survivors in a nearby health care facility, my colleague came to recognize that there was great need for (and strong interest in) health-based coaching that focuses on this recovery process. He began meeting with new clients who are similarly in recovery from strokes. He helps them identify ways to sustain their new healthy habits, while also helping them build new relationships with family members (who are suddenly concerned about his client’s disabilities and even his client’s mortality). As noted by Atul Gawande in his remarkable book, Being Mortal, this is certainly the right time for his clients to engage in critical conversations with significant others regarding the near and distant future.
Tier Three: First-Order Prevention
A health psychologist can engage prevention strategies that discourage or block behaviors leading to illness or injury. The Tier Three health-based coach is helping her client who is standing at the edge of the cliff to avoid falling off the client. She helps her client to identify and engage healthy practices that reduce the chance of injury or illness. As in the case of Tier Two coaching, the Tier Three coach often engages in some tough questioning (“why do you think you are hesitating to start up this new health-based practice?”), some monitoring (“your blood pressure seems to still be quite high”) and some encouragement (you have taken an important first step!).
Tier Three coaching is especially valuable with regard to life style changes (nutrition, exercise, sleep). As in the case of Tier Two, the health-base coach might help her client with stress management and the continuing use of preventative medications, Environmental safety (inside home and work place) can also be an important (and unique) source of monitoring (and questioning) by a health-based coach – especially if her client is elderly (and living in a home that has not be retrofitted for the unique safety needs of her client).
I illustrate this Tier Three coaching strategies with an event that occurred in my own life. The health-base “coach” in this instance is a gifted and dedicated physician who found a way to spend quality time with her patients (many of whom were other physicians). She made extensive use of appreciative strategies (without ever having read anything about this approach to human interaction). She and I had focused during the previous year on my weight. I had not been very successful in losing weight and was even considering the cancellation of my annual medical appointment with my physicians given this failed attempt to lose weight.
My physician and I met and, sure enough, not any loss of weight. I was waiting for the critical review by her (and by my own super ego). Instead, my physician offered the following appreciative (and challenging) observation: “while you haven’t lost any weight, you haven’t gained any—so let’s look at what you are doing right. What are you now doing to avoid gaining weight and let’s see if more of this will help you lose weight?” I was caught! It was not a matter of simply giving up as someone who was not capable of managing their weight. I was still accountable and was not helpless. We reviewed the slight changes in my health habits and she suggested that I focus on two of these changes: (1) spending even more time in walking my dog (for exercise) and (2) continuing to cut back on my consumption of specific foods (that were not necessarily my favorite, but were what I had grown up eating—habitual behavior).
Tier Four: Second-Order Prevention
Finally, a knowledgeable health psychologist can advocate and lead a shift in public attitudes– moving people to health-oriented values, priorities and perspectives regarding their own life and the life of other people in their family, community and society. The Tier Four health-based coach, in essence, is asking the fundamental question: “why are you (we) all living on the edge of the cliff?” The option is to move away from the cliff. The health-based coach is helping her client or client system in effective advocacy regarding creation of healthy communities (moving away from the cliff).
Everett Rogers’ (2003) model of innovation diffusion can be a valuable guide in the promotion of ideas and practices related to healthy habits and environments, as well as health-related public policies. The Tier Four coaching can help her client find ways to support those involved in the early implementation of healthy community policies and practices (Rogers’ early adopters). A Tier Four coach can also assist her client in the gathering and presentation of persuasive information regarding the effectiveness of healthy community policies and practices (Rogers’ early majority). Finally, the Tier Four coach can help her client or client system in devising ways (e.g. social media) of persuasively informing the general public about specific healthy community policies and practices that are now commonly in place and are the “norm” (Roger’s late majority).
You will notice that the Tier Four coach usually ceases to be a neutral party. She is committed to health and to the initiation of health-oriented public policies. Furthermore, her clients are often not individuals or even families or community groups. The coaching client is often an entire health care system, public agency or government office. Tier Four coaching is “big picture” – and not for the faint of heart—but it is essential.
I have recently helped to found an inter-community service agency—called “Communities Collaborating”—that is helping to set up programs that offer Tier Four (as well as Tier One, Two and Tree) health-based coaching in isolated communities (“islands” that might not be surrounded by water but are just as separated from major population centers). These communities are frequently populated by senior citizens who are “caught” in their homes (either be choice or because of economic exigencies). They are also often “caught” in a life style that is not conducive to sustained health (though they have managed to live many years without a major concern for nutrition and finish each day with a shot of whiskey or a smoke!!). Communities Collaborating is in the business of advocating for healthy practices (nutrition, exercise, sleep), while also helping to set up transportation for the elderly to health-care appointments, and providing the elderly with knowledge and assistance regarding health-related financial matters (e.g. government assistance programs, appropriate insurance plans).
These activities, as well as others being advocated by Communities Collaborating integrate all four tiers with a focus on building healthy communities and sustained services for senior citizens in the island communities that participate in this collaborating venture. While Communities Collaborating is not itself directly providing these health-based coaching services, it is providing training for local community coaches and, most importantly, identifying best practices that already exist in the participating communities and providing venues where these best practices can be shared with leaders of the other collaborating communities.
A Career in Health-Based Coaching
As in the case of a career in personal or organizational coaching, someone wanting to be a health-based coach probably must be blessed with or cultivate a entrepreneurial spirit. If you choose to work in this area, you will be a pioneer and a visionary. The work will undoubtedly be challenging – yet the financial rewards and sense of personal satisfaction in being of valuable assistance to other people are clearly available.