A Hierarchy for Health Coaching

by Dr Ollie Hart

Have you always thought a hierarchy was a bad thing? We often think of this word when describing the power dynamics in groups…people compete for the top spot, to be the boss - the one who gets to control what happens. These days, we are often trying to flatten hierarchies and share out the power, recognising the value of diverse shared leadership and decision making. I’m not talking about this kind of hierarchy.

When it comes to complex processes like health coaching, I think having a hierarchy to consider how the approach is applied can be really helpful. It helps us to consider the foundations of health coaching, the most important place to start, and to make sure it is firmly established before you work up the hierarchy. At the peak of the hierarchy you might have the most sophisticated activities, what some might consider the ‘icing on the cake’, but without the cake you have nothing to decorate.

I have suggested three levels in this relatively simple hierarchy. I like simple: it’s easy to remember, a bit like the ABC (airway, breathing, circulation) of life support - there is an order to follow.

At the base of this hierarchy, I have self-belief. Here I mostly mean the belief that the person being coached has in themselves (although spare a side thought for the self-belief of the coach too). Do they feel confident to be involved, do they believe in themselves, do they believe that they are worth valuing, and that it is worth them being involved? So often, people come to health coaching feeling like a failure, overwhelmed, and with low self-esteem. In most of us there is some element of self-doubt at some points in our journey.

Ensuring people know what they want, and why it is worth pursuing this is so key to health coaching. This doesn’t require any specific health knowledge; it requires the core health coaching skills that are relevant to everyone no matter their situation or health condition.

When we teach health coaching we very much start here. And often, health coaching sessions will need to focus all the time and effort building self-belief. I would argue that this is the most important function of health coaching, and that if this was ‘all you did’ as a health coach, you’d likely be setting them up to improve their health.

Nevertheless, when a health coach has established that there is enough self-belief, they can then approach the core health enablers – the next tiers in the so-called ‘cake’. These are the lifestyle pillars and the social determinants of health. These are really two levels, but I place them side-by-side as it’s hard to prioritise one over the other. There will be different standout strengths and weaknesses here.

You may be working with a well-paid manager, in a secure job and stable housing, with plenty of supportive friends and family - but with high work stress, smoking and eating and sleeping terribly as a result.  Alternatively, you may be working with someone living in poverty, struggling to look after unwell family members, where their social situation dominates their capability to live a healthy life.

The apex of the hierarchy is learning and delivering self-management techniques specifically related to the health conditions that people live with. We see increasingly effective practices that health coaches can teach people to help manage chronic pain, intrusive mental health issues, or to stabilise a dysfunctional metabolic system. As we deepen our understanding of the interactions between the mind and the body, and their effect on wellbeing, we can utilise new techniques around, for example, movements, breathing, or psychological strategies. These may sound simple, but as our knowledge of the workings of our nervous system, hormones, and thought patterns evolve, so does the sophistication of which we can support people to find the right practices and approaches for them.

As a doctor and prescriber, I understand the value of medication and medical interventions to improve people’s health and wellness, but I increasingly appreciate the synergistic and supporting role that sophisticated and personalised health coaching can play to ‘activate’ the natural healing processes of the mind and body.