Coaching an unregulated developing field
is a relatively new service available to people who feel like they need help to make changes in their lives. Coaching first got a foothold in business, with mentorship and supportive services helping people to achieve professional goals
in their lives. Motivation enhancement is a key component of many coaches’ repertoire, as they help people to set goals, and then both hold them accountable and cheer them on as the clients make progress towards these goals.
Just a few years ago, life coaches were largely shying away from the complex issues involved with mental health, and recommending that such issues remain the purview of psychology and counseling. No more. A quick Google search for “life coaching mental illness” turns up dozens of online links, with many who now explicitly market coaching services for mental illness issues (such as: this one, or here). The National Alliance on Mental Illness (NAMI) is even now piloting a coaching program for those who live with mental illness.
Recovery Coaching is a new offshoot, where coaches explicitly support individuals who are trying to recover from the effects of behavioral conditions, including mental illness, though most often focused on the broad (overly broad in my opinion) category of addictions. Wellness Coaching is another offshoot, where coaches offer support in areas like weight loss or healthy activities.
As a psychologist, I’m struck by the shift that such coaching signals for the industry of healthcare. By and large, I think this is a positive trend, emerging in response to need. However, there are important issues to consider, as coaching intersects more explicitly with mental illness.
The majority of coaches are paraprofessionals who do not hold licenses or advanced education in the field of mental health. This isn't necessarily bad. Coaches aren’t interested in doing long-term insight-oriented work with a client, but have a primary role of helping a client achieve demonstrable change and results.
Drop and give me twenty life changes!
Many Recovery Coaches identify as people in recovery themselves. This may come from the model of the “sponsor” in 12-Step programs, where someone who’s worked the steps towards sobriety serves as a mentor, guide and support to people new to the process. “It takes an addict to know an addict,” underlies the approach, and is a principle adopted by Recovery Coaches. This cuts both ways though, as such a subjective focus on one’s own experiences can blind us to the different experiences of others.
Another parallel to coaching is the recent rise of “peer specialist” services, primarily in publicly-funded behavioral health services. There, people in recovery from mental illness or substance addiction receive training and supervision to support their peers in achieving treatment goals. For several years, I’ve been working on a federally-funded project developing a peer specialist model of service for rural LGBT individuals living with mental health issues, as well implementing an Assertive Community Treatment, which utilizes peer specialists. Designing the training and operations of these programs has given me a frontline view of the benefits, and risks, of the coaching/peer specialist model.
Here are a few of the issues where paraprofessionals such as coaches and peer specialists need support as they work with mental health issues. Both coaches and their clients will benefit from clear training, education and supervision in:
- Ethics and Boundaries: Because coaching is unlicensed and unregulated, there are no clear boundaries. In AA, sponsors are prohibited from having sex with their sponsees, and of course, licensed clinicians are similarly prohibited. But no such boundaries or rules govern the practice of coaches. Some coaching organizations have set responsible ethical codes, but participation in these group is not universally adopted or required. Likewise, issues of finances and collection of bills is an issue specifically addressed by licensing boards, but because coaches work independently of such oversight, they are free to engage in whatever actions they deem necessary to pursue collections, including harassing emails or phone calls, or using collection agencies without client consent, actions severely governed by licensing boards.
Abandonment: Licensed clinicians can face serious charges and liability if they “abandon” a patient in need, even if that patient has an outstanding debt. The clinician has a fiduciary responsibility to that patient, to ensure they receive good care, and/or a referral to another provider or resource. Such requirements don’t exist for coaches.
Therapists can't abandon patients. Can coaches?
- Confidentiality: Does HIPAA (Health Information Portability and Accountability Act) govern coaching? If it’s not a part of formal healthcare, the answer is no. If a coach inadvertently (or purposefully) violates a client’s confidentiality or privacy, the client may have no recourse. Given that coaches lack training in the rules of confidentiality in healthcare and such relationships, they may not even be aware of some of the subtle forms of disclosure which might be damaging to their clients.
- Liability: A licensed clinician is required to carry substantial liability and malpractice insurance. This protects their patients, assuring that, if harmed, the patient may seek compensation. While malpractice insurance exists for coaches, there is no requirement that a coach has such coverage. As a result, if things go bad, a client may have no recourse, other than posting bad reviews about the coach.
Medical and Medication issues: In today’s healthcare world, medical integration is the name of the game, and licensed mental health clinicians are often the frontline of identifying when medication may assist a patent, or, in identifying when certain problems like sexual dysfunction may actually be a side-effect of medications. People in recovery from mental illness and addiction often come with their own complex history and relationship with medications. Many in recovery from drug addiction view psychiatric medications as equivalent to drugs, and advocate against them. This may help some individuals, but definitely not all.
Medications are an important part of treatment
- Suicide: Frankly, even doctors and therapists are often poorly trained in the assessment and prevention of suicide. Coaches are even less so, simply because there is so little good training available to the nonclinical population. And yet, people struggling with addictions, relationship problems and financial struggles are at very high risk for suicide. Coaches may miss important, subtle cues of suicide risk.
- Self-Care: Coaches in recovery need strong support and great self-monitoring skills to maintain their personal functioning and life success. Dealing with the issues of people struggling with the same problems can be a powerful trigger and stress, which might even lead to a relapse. Clinical supervision for peer specialists and clinicians is in place for just this reason.
In Over Your Head: Let’s be clear – it takes a certain level of arrogance and confidence to believe you can help fix other people’s problems. That confidence is a double-edged sword, for therapists and coaches. One thing that licensing boards want to hear from candidates is that they know when to call for help, and seek consultation. A therapist gone rogue, acting like the Lone Ranger wearing Superman’s cape is a very dangerous thing for patients. This is one reason why peer specialists are typically required to have ongoing clinical supervision, and why sponsors are required to have their own sponsors. Most coaches operate independently, with little professional support and may become isolated. Many coaches use forums and message boards to seek such support, which can be a helpful resource, though is only as reliable as is any advice or information on the Internet.
What do coaches do with challenging issues?
If it sounds like I’m against the idea of coaching, let me correct you. I don’t go to the beach and try to stop the tide, and I’m not interested in opposing coaching. With the availability and freedom of the Internet, it’s most likely unstoppable. Plus, I truly think there is tremendous value in coaching, and peer specialist services. Such paraprofessional services offer a cost-effective support in a healthcare system that is cash-strapped and resource-poor. Australia and Great Britain are just two countries that are already exploring the use of a tiered behavioral healthcare system where such paraprofessionals provide easily-accessible low-end services, thus utilizing the higher-level professional services more effectively. However, both systems have tried to protect clients and ensure good outcomes, by setting up certification, monitoring and supervision requirements for the paraprofessionals.
Until such requirements come to pass in the world of coaching, if they ever do, it’s up to the coaches themselves and the informed consumers, to monitor for the above pitfalls. If you are a client seeking coaching, I encourage you to carefully interview a prospective coach, about their boundaries, their liability protections, the effectiveness and reliability of their methods, and make sure there are clear written guidelines around finances and confidentiality.
Coaches may one day want to merge with the developing peer specialist model of care, and be able to seek reimbursement other than cash (and thus serve more people in need). I believe most coaches are well-intended people who want to provide good, effective support to their clients. To do so, I invite them to ensure they are considering these issues in their practice and businesses.
*This article was written at the thoughtful suggestion of my friend and colleague, Craig Perra, coach at Feed The Right Wolf. Craig and I disagree on addiction, but agree on the need for good ethics and rules to protect clients.