There are many psychological models and theories that are utilized in health coaching. It’s because of the psychology used in health coaching that I know there can be a lot of gray – not just as a coach, but also from the client perspective too.
I’m not a therapist and there are limitations to how I can dive into issues with clients and the kind of issues I can explore.
This post will talk about the models that are used commonly in health coaching and why I believe we should overlap them strategically when working with individuals (and groups).
What is health coaching?
This question never really gets easier to answer, but I use evidence-based strategies and interventions to guide conversations and engage clients in self-reflection so that we can create a safe space for them to be vulnerable and honest to allow for change.
This is what I want to tell potential clients, but I know they want to know if I can give a meal plan (resounding no), help them achieve their goals (maybe) and achieve them quickly (honestly, probably no).
I do tell them that I work with individuals to become empowered to explore and make decisions that are best for their health. Sometimes that includes identifying stressors that influence their behaviors and exploring other coping mechanisms, sometimes that’s navigating cognitive distortions and advocacy with other health professionals, sometimes it’s exploring what health means for the individual and setting goals that build towards a long-term change.
I heavily encourage clients to reflect in different ways so they can improve health on their terms in a safe and sustainable way because often, no one has asked them to do this, but you will not want a coach or trainer for life. My job is to give you tools so you can take charge. I also use other certifications and experience to work with clients in other capacities and dive deeper with weight training and nutrition education.
Sadly, many would be surprised to learn how unregulated health and wellness, (which is why ethics matter) which is why there are MANY people who practice far out of scope.
This isn’t to say that there aren’t directives in health coaching, there are times when a client needs education or more guidance, but more often it’s collaborative.
What models and psychological theories are used in health coaching?
- Maslow’s Hierarchy of Needs
- Prochaska’s Transtheoretical Model of Change (TTM, Stages of Change )
- Cognitive Distortions
- Health Belief Model
- Self-efficacy concept
This list may be longer and there may be some theories and models that are similar to those mentioned above, but these are the ones that I use most often.
What are techniques used in health coaching?
- Motivational interviewing
- Active listening
- Positive listening (unconditional positive regard)
- SMART goal setting
Other techniques or skills I utilize in my practice – my ability to get curious and problem solve. Here and there, I will work with clients to help them research issues like unemployment in their state or connecting them to other professionals; giving them enough support to then take the reigns as some of those things can go out of scope.
As I’ve continued to evolve as a coach and explore public health further, I’ve realized the importance of overlapping these models and theories. Focusing on them individually can give us a starting point, but seeing their intersection highlights the complexities of behavior change and living a healthier life.
Below are two models I overlap the most.
The Stages of Change model or Transtheoretical Model (TTM) by Prochaska, et al., helps us understand the different phases (5 to 6 phases) a person goes through when they want to accomplish a goal. The model starts with pre-contemplation (before the person sees the need for change) and ends with maintenance (the habit is part of new normal). Understanding these phases can help us meet people where they are and guide them forward to the next phase on their own terms.
It’s ok to ebb and flow between phases, but it’s understandable that this can be frustrating. During contemplation you may repeat your goal a million times over months or years before finally feeling ready to create a plan so that you can move into the preparation and action phases. While there’s research that shows these phases could last a specific amount of time, from working with a few clients for multiple years, it’s clear that timelines are personal and by examining other models and theories to TTM, there’s other explanations for why moving from one phase to the next can be challenging.
The hyperlink to Boston University’s School of Public Health shows this cyclical nature of entering and exiting phases.
As a coach, using active listening and motivational interviewing techniques, I can learn about their goal itself, but also what barriers the clients has (real and perceived), what they’re ready to change and work on together to create a plan as well as what they’re not willing to work on yet. I won’t say that these skills are easy – they are hard, but they’re a practice and it gets easier. Often I see that it can be uncomfortable for clients as they’re not used to someone asking questions and having a desire to learn the answer. Many ask a question so that they can respond, which can make it hard to want to bring up certain topics.
Adding Maslow’s Hierarchy of Needs to Prochaska’s TTM can help us see the complexities in those barriers that may be preventing movement in behavior change. Maslow’s pyramid is broken down into five different categories that can be grouped in three kinds of needs.
Maslow’s structure shows that foundational needs must be satisfied before an individual can elevate in the pyramid, however, satisfaction can vary and don’t need to be 100% satisfied as he later admitted.
Below I’ve redesigned the pyramid that shows the categories with the traditional ideas of what falls into each, but also includes some other ideas for those who have a hard time seeing gray and adapting these models individually. I’ve also used dotted lines to show the fluidity that can occur between levels.
This is really where the talk starts.
While the categories don’t change in the pyramid, the needs within them do and I think it’s important to look at these models and then insert your own personal needs, which is what I have done in bold in the above pyramid.
It’s also possible that there are some needs like non-judgmental support that doesn’t just fall into safety needs, but also belonging or esteem needs.
Now combining the two ideas, let’s use the following examples.
Example 1: For a type 1 diabetic, (man-made) insulin is a physiological need. While there are small changes that can be made like monitoring diet, many still need insulin injections to help regulate their blood sugar because their pancreas cannot make insulin.
Example 2: Recently, a client was prescribed medication for depression and had apprehensions about using it to help them feel better. They’re thoughts were that they “couldn’t figure it out on their own“, they were “failing“, they were “broken” and they were “lazy“.
The thoughts of example 2 are reflective of black and white thinking, mind-reading and shoulds/musts distortions, but that’s a talk for another time. These thoughts show that they felt there was one way to manage their depression and that meant alone without medication.
Example 2 is a client and is familiar with Maslow’s Hierarchy of Needs from their profession. They also had a loose conversation using Maslow with their prescribing doctor too, which helped to open this conversation.
We started with their bigger goal of living a healthier life, which may include weight loss, but primarily focuses on feeling more confident and comfortable in their body and learning to create a routine while being flexible.
They explained that they know what they need to do like workout, eat better (than they had been), plan ahead, get more sleep, but that they can’t.
Using the context that they provided of a busy work schedule, I asked ‘why do you need to do those right now’ and I had them reflect on what they see when they think about a healthier life overall. “I don’t know, I like to exercise, but I’m just too tired after work.”
Client just started a new job …during a pandemic.
We continued to talk about where the distortions came from because while it’s helpful to identify the distortion and the counter thought, without a connection to where it came from it can feel judgmental and shameful to have the thought or challenge it.
It turns out they don’t believe others using medication are failures, but conversations around them have made them believe this shouldn’t or couldn’t be an option. That’s powerful.
We then started breaking down the pyramid, filling in the categories with things that supported them.
While they said that they want to eat better we talked about how physiological needs isn’t about a perfect daily diet or eating pattern, it’s about eating as a baseline. That you need to have access and if there are days that they’re wiped out, access may be a sandwich or a hot dog. But from what they were describing, having a quick meal like a hot dog or sandwich wasn’t something that they wanted to do everyday.
So we looked at the other needs and I proposed medication as a physiological need to help provide a baseline using the first example of a type 1 diabetic with insulin. It is NOT the fault of the diabetic that their pancreas isn’t working and their body is attacking itself, so why is it the fault of someone whose body isn’t producing hormones that help with their mental health?
Using medication is a tool and there will still be work to be done to help them lessen or get through depressive episodes, but that work doesn’t matter if the root cause to the depression isn’t focused on, which is something they’re working on with their therapist (not me).
Our work will look like goal-setting each week taking into consideration how they’re feeling since starting medication and beyond. It will continue to look at cognitive distortions and encourage them to bring up certain points to their therapist. It will continue to encourage them and hold space that they’re not failing.
Goal-setting and creating plans for ourselves rarely involves just us. While Prochaska helps us break down our behavior, it minimizes the influence of external ideas on our choices. Maslow offers a helpful framework to help us better understand how our choices are affected by our environments, but we need to continue to make this individualized and lessen the black and white view that can occur from seeing the categories.
Offering space for reflection and acceptance to help peel back the layers that influence us in our daily lives from cultural beliefs to systemic racism is powerful. Being fluid with approaches to our health can help lessen guilt or shame that are often associated with choice. Being strategic when we listen to clients (and others) to meet them where they are and hear what they really need helps empower them to see themselves with less judgment.