Coaching a Client Through To A Mental Health Referral Using The Stages of Change

Times arise when it becomes apparent to a wellness coach that their client would benefit from working with a mental health professional. The need for referral may be urgent and involve client safety as when there is a threat of harm to self or others. That rare situation is usually more clearly recognized, referral is made and coaching is usually terminated. (“Top Ten Indicators to Refer a Client to a Mental Health Professional.” This can be found in the Wellness Resources section of the Real Balance website:https://www.realbalance.com/wellness-resources ) (See also this previous post: The Wellness Coach And Referring Clients To A Mental Health Professional: PART ONE – WHEN (http://wp.me/pUi2y-bA) )

More common is the situation where the client raises issues where there is no immediate danger or threat, but rather, there is either a history of unfinished emotional issues, or there are current circumstances that are creating barriers for the client’s effectiveness at succeeding at lifestyle improvement. In such situations, having a thorough working knowledge of the difference between coaching and therapy is essential for a professional coach. The best possible resource for this is this article by Meg Jordan and John Livingstone (https://www.realbalance.com/wellness-resources).

Resolution Vs. Relevance

How is the past affecting the present?

The first step would be for the coach to explore with the client to see if they are currently in therapy for these kinds of issues, or have been in the past. Then, the coach and client may be able to explore if they can coach about these issues, not to resolve them, but to see how they obstruct progress in the client’s efforts at lifestyle improvement. Can they be accounted for and worked with in coaching, or are the challenges so great that they will actually prevent progress in the coaching?

Well-trained coaches can do process coaching. The key here is to seek how the emotions of the client are relevant to the progress they are attempting to achieve in coaching. Perhaps a client repeatedly holds themselves back from engaging in the wellness/self-care activities that the coach and client create as action steps in their wellness plan. As this is discussed an internal barrier is identified that traces back to their family of origin. Perhaps a critical parent harshly enforced that all work must be done before one does anything for one’s self. Now, the goal of doing process coaching around this is not the resolution of all of the feelings and unfinished business with that parent (be they dead or alive). Instead, it is to gain insight regarding how these past learning’s are holding them back today. If the client is able to gain such insight and translate it into action (moving ahead with self-care) then the process coaching is achieving its goal. If the client continues to only process feelings and does not gain insight or does not succeed in shifting their behavior, then, we have probably identified an issue that is significant enough to warrant the encouragement of referral to a counselor or therapist.

In such cases or if the issues are beyond the scope of coaching and are interfering with client progress, then exploring making a referral needs to begin. How to make this referral successfully is not as simple as explaining the benefits of therapy and providing resource information. Very often clients are ambivalent, or even outright resistive to a referral to a mental health professional. The thought of reconnecting with all of the unpleasant emotion involved in working directly on their issues in therapy brings up fear. Unfortunately, coaches sometimes drop such a client quickly when they are not ready to jump into action and seek out the therapy they would benefit from. This is where a client would benefit from a coach who implements a Stages of Change approach (The Transtheoretical Model of Change developed by James Prochaska).

In the new book by James and Janice Prochaska Changing To Thrive (https://www.prochange.com/uncategorized/2017/02/prochaskas-new-book-changing-thrive-published), they make the point that most of the people we all work with are not in the action stage of change on any particular behavior. They estimate that only about 20% are actually ready to jump into action. Why would this be any different when it comes to engaging in counseling or psychotherapy? Yet, so often, when the client balks at following through on a psychological referral, coaching is abandoned. Instead, think of it as our job to help the person to weigh the pros and cons of engaging in counseling as they sit in the Contemplation Stage of Change. We are helping them with Decisional Balance. Taking a page from Motivational Interviewing, we coach as they work through their Ambivalence. We want to “roll with resistance” instead of accepting it as a rejection of our referral recommendation.

Coach THROUGH to referral!

Coach: So, I hear your hesitance when I suggest that counseling might be the best way forward with this.
Client: Well, yes. I’ve been in counseling before and I don’t know if I want to open up that whole issue again.
Coach: Sounds like you possibly have some fear about talking about such uncomfortable subjects again.
Client: Yeah. Growing up in my home was not a pleasant thing!
Coach: I know it holds a lot of negative memories for you. You’ve shared some stories about how bad it was. Yet, I also hear you saying that it’s frustrating to have these things hold you back from doing what you want to do today to be healthy and well.
Client: Right! It’s really frustrating! I know I need to get more active and take more time to eat right, but then I feel so guilty when I take time for myself.
Coach: So, on the one hand you really want to make these improvements to your lifestyle, but when you attempt to do so, these barriers, these thoughts get in the way.
Client: Exactly! I appreciate your help, but it seems like whenever we set up action steps, I never follow through on them, even though I know I need to.
Coach: Yes, we’ve explored how it’s all related, but we still seem stuck. What do you think would be the benefits if you did get back into counseling about this?
Client: Well, I guess I could really open up about it and try to unload some of this frustration. I’m just so tired of having the past hold me prisoner!
Coach: So a counselor could actually help you explore that and really make some progress in this area, perhaps result in some relief.
Client: Yeah. Okay. So what’s next?
Coach: Well, let’s work together on reconnecting you with some counseling. Let’s see what steps you can take to find the resources you need.

In this example the coach meets the client where they are. They help their client to Contemplate the idea of returning to counseling. Acknowledging the client’s fears and validating their feelings, the coach helps the client to begin to weigh the reasons to return to counseling and the reasons to avoid it. The family of origin stories are referenced, but not delved into. Instead, the emphasis is on relevance. How the past is getting in the way of the present is the essence of the contemplation. Then, at the end of the example we begin to move into the next Stage of Change; Preparation.

Coaching works because we are the client’s ally through the whole behavior change process. When referral comes up, we remain their ally. Then to help them actually follow through and make it to the referral resource, we help them with the process of identifying such resources, making the appointment, and attending the appointment. We offer support and accountability with all of the action steps required to achieve this preparation. We acknowledge the courage, the valuing of one’s self that is required for each step along the way.

James & Janice Prochaska with Michael Arloski

Take what you know about the Transtheoretical Model of Change (Stages of Change) and apply it to the referral process. Be your client’s ally when they need you the most.

 

SPECIAL ANNOUNCEMENT:  James and Janice Prochaska will be Dr. Arloski’s guests on the Real Balance Free Monthly Webinar – May 26 at Noon Eastern Time.  This will be a special one-hour webinar where the Prochaska’s will be sharing their breakthrough work from their new book CHANGING TO THRIVE.

“Changing To Thrive: Using the Stages of Change to Overcome the Top Threats To Your Health and Happiness” An Interview with James and Janice ProchaskaRegistration URL: Registration URL: https://zoom.us/webinar/register/bd820be2db187da1c5b9141539e44ee6

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Healthy Boundaries For Health & Wellness Coaches: Part Two

Boundaries Are There For A Reason
Boundaries Are There For A Reason

In our last post we featured Part One on this topic:

A New Code of Ethics For Health & Wellness Coaches: Healthy Boundaries Part One   http://wp.me/pUi2y-kb There we introduced the new NCCHWC Code (National Consortium for Credentialing Health and Wellness Coaches) and began the discussion of boundaries with a look at ethics, appropriate relationships, touch and self-disclosure. We talked about the establishment of a trusting environment and how coaches show respect for boundaries by asking permission to explore sensitive areas. In this blog we’ll take a deeper dive into some specific areas where coaches often have questions about how to proceed.

Pushing The Edge

In health and wellness coaching boundaries can be pushed by either the coach or the client. When is a client asking for too much? When is a coach straying either beyond their Scope of Practice (see NCCHWC website: http://www.ncchwc.org/wp-content/uploads/2015/03/Final-NCCHWC-Health-Coach-Scope-of-Practice.pdf) or enters territory that simply feels uncomfortable for either party, or both?

boundariessoccerflagClient-Generated Boundary Crossings

  • Asking for reminders, contact beyond appointments, services not in the contract and personal inquiry.

 

When clients co-create with their coach agreements about action steps and accountability they frequently begin by asking for the coach to remind them to perform that action step. This is not an outrageous request and one that some coaches are okay with. What works better, however, and is much less of a burden on the coach, is for the client to agree to contact the coach (via email, text) to let them know when they did, in fact, perform the action step. This keeps the client more responsible and allows the coach to avoid falling into the role of nag or authority. Coaches should always agree only to what they are willing to do when setting accountability agreements.

Clients may also ask for additional contact beyond the agreed upon appointments. This request can arise out of a variety of intentions. Clients may desire more of a friendship relationship instead of a professional coaching relationship. This could even have romantic intentions. This is where using direct communication is a coaching skill that can pay off. The coach should gently inquire about the client’s intention in making such a request. This brings things out into the open and can lead to a helpful coaching conversation about where else in the client’s life they could get such needs met. The coach can gently, but firmly explain the advantage for the client in keeping the coaching relationship on a professional level.

I once trained a coach who had gotten into a coaching relationship where she would come to the client’s house, wake her up at 6:00 am and go jogging with her as part of the coaching service. I asked if their agreement was for coaching or for services as a personal assistant! There is quite a difference to say the least. Stick to coaching! When clients make excessive requests, explain the roles of a coach and explore how else the client might get these other needs met.

The other area coaches are often unclear about is how much to disclose about their own personal lives. We address self-disclosure in coaching very thoroughly in my previous blog post: “Self-Disclosure in Coaching – When Sharing Helps and Hinders” (http://wp.me/pUi2y-8m). To quote from that post: “Coaches choose to share certain biographical information with their clients to help build the coaching alliance. The coach who comes across as secretive about whether they have ever had children, are in a relationship with a partner, etc., is going to be trusted less. The challenge here is to maintain good professional boundaries while also being willing to relate to the client as an ally, an authentic human being, not an impersonal and distant professional.”

boundariescalmCoach-Generated Boundary Crossings

 

  • Going Beyond Competency – Beyond Scope of Practice

 

In Part One on this topic we addressed professional scope of practice. (See NCCHWC Health & Wellness Coach Scope of Practice http://www.ncchwc.org/wp-content/uploads/2015/03/Final-NCCHWC-Health-Coach-Scope-of-Practice.pdf You can also find copies of both the Code of Ethics and the Scope of Practice in the Wellness Resources section of the Real Balance website (https://www.realbalance.com/wellness-resources)

Looking more closely at what happens at times in coaching, we see that the edge that is pushed here is often done subtly and usually without intent to go beyond coaching. The number one concern I hear about in training coaches is the distinction between coaching and therapy. Again, look to the Wellness Resources section of the Real Balance website listed above for a copy of the definitive article on this subject by Meg Jordan and John Livingstone Coaching versus Psychotherapy in Health and Wellness: Overlap, Dissimilarities and the Potential for Collaboration.”

What I observe more frequently is when coaches pursue a line of inquiry into a client’s psycho-emotional history, into their family of origin issues, etc., and sometimes do so based upon methods and techniques that they have read about in various self-help books. Without a mental-health professional background, even attending a workshop with a famous self-help author does not prepare a coach to do such work. Such inquiries usually do not develop into dire mistakes, but do have the potential to urge the client to go somewhere emotionally that they and the coach are not prepared for. The number one brake here is for the coach to catch themselves when they realize they are engaging in this line of inquiry more out of their own curiosity/fascination instead of a solid coaching rational. When clients push to pursue this inquiry it’s time for the coach to state their own lack of qualifications to go there and to suggest how the client could be better served by speaking with a counselor, therapist, etc.referrals

 

Going beyond one’s competency can also occur outside of the mental/emotional dimension of wellness. It’s so easy for a coach to blur the line between providing some helpful wellness/health education and being more directive. Coaches should refrain from recommending, imploring, strongly suggesting, or arguing for the benefits of a particular course of action (such as a specific diet, exercise plan, or any form of conventional or non-conventional type of treatment) if they are not qualified to do so as a licensed professional in that field. The coach who can “wear two hats” can offer the wisdom of that other profession that they are part of when they clearly inform their client that they are doing so. This step “over the edge” can occur easily when the coach is not aware of how they are pushing their own agenda for change.

  • The Coach Acts Out Of Their Own Needshands-of-couple-reaching-for-each-other-resize

A boundary is crossed when the coach is no longer acting with the good of the client remaining primary. Coaches are fallible human beings like everyone else. Unmet interpersonal needs for intimacy, whether sexual, romantic, or simply the desire for closeness, can influence the coach’s actions at levels that require keen awareness to detect. Part of being a health and wellness coach is living a wellness lifestyle and that means acknowledging one’s needs and seeking healthy ways to get them met. Unmet needs for power and control, for self-worth through showing competency can also be expressed by coaches at an unhealthy level that once again causes the coach to no longer be acting with the wellbeing of their client as primary.

Coaches can also put their own needs first on the financial front. The coach who is facing severe financial stress may consciously or unconsciously strive to create more dependence in the coaching relationship instead of fostering independence in their client. Coaches who also sell wellness products, such as supplements, etc., may pressure clients to make purchases (a clear violation of the Code of Ethics).

  • Social Media Boundaries

Clients sometimes actually brag about having a coach and are proud to tell the world about the wonderful services that Coach X is providing for them. Coaches however must respect their client’s confidentiality and not identify any client on Social Media (Facebook, Twitter, etc.). It is also not a good idea to “friend” clients on Social Media. Clients can share information using more private methods of communication than a Social Media format that provides no privacy.

robo-coaching

Organization-Generated Boundary Crossings

 

  • Violating Client’s Right To Confidentiality

 

Most organizations are careful to avoid violating the privacy of their employees but this can happen when coaches working within an organization are asked to give specific reports on their clients. HIPPA regulations (https://www.hhs.gov/hipaa/index.html) protect the health information of a client. The request for information about “how a client is doing” may come innocently enough out of genuine concern for the client. Still, this request should be met with a recommendation that the person inquiring ask the client directly.

  • Requiring Internal Coaches To Push Sales

An organization may require the coaches that work for them to promote the sales of products or services within the context of the coaching. While this may be framed as a low-pressure offering that clients can easily decline, it is potentially an exploitation of the unique trusting relationship that the coaching process develops.

  • Requiring Internal Coaches To See Too Many Clients

Another boundary is that of setting healthy expectations/requirements for the number of clients a coach can see in one hour and in one work day. Some disease management and other large coaching services make excessive demands of their coaches in terms of quantity of clients seen, lack of break times, and lack of times to do coach notes, etc. The result is both a health risk for the coach and inevitably a diminishment of quality of services for the clients.

Organizations and coaches share in the responsibility and potential liability of working with the people they serve. They must always act with the good of the client (and the coach) – their health and wellbeing – as foremost in all policies and procedures.

Coaches also need to think about how they may at times be putting themselves at risk. One example would be if a coach meets a client in a building where they are the only occupants, or especially if the coach opened a locked building to meet with the client there.

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Healthy Self-Generated Boundaries

  • Knowing And Abiding By Your Own Limits & Boundaries

Perhaps the most rewarding benefit of Healthy Boundaries is the self-care that they provide for the coach themselves. We benefit from all of the healthy boundaries described above, but we also need to reflect on the boundaries that we need to set for our own mental, emotional and spiritual health and wellbeing. Sometimes coaches work in settings where excessive demands are made of them as we noted above. Independent coaches however, need to set their own limits and achieve healthy boundaries in order to preserve their own wellness and continue provide the highest quality services. Part of the self-employed challenge here is having enough confidence in your own ability to create a successful business that will support you to allow  you to invest in the time it takes for self-care and personal and professional renewal.

Boundaries are there for good reasons. Just like a football game or match would become chaotic without those “out-of-bounds” markers, professional and personal relationships thrive on clear and healthy boundaries.