In this first of two articles on telecoaching, behavior change expert David Anderson, PhD recounts his experiences in the early days of “telephonic health coaching”, as the field was just beginning. David discusses the major lessons they learned as the practice evolved, the research that has demonstrated its efficacy, and where the industry is today.
I’m not sure my team and I invented telephonic health coaching, but we were pioneers in developing this approach. StayWell was a market leader in workplace wellness programs by 1992. An important problem we were struggling to solve, however, was that many of the employees of our large employer clients worked remotely or in very small offices and didn’t have access to our health behavior change toolset. Group “classes,” the primary mode of delivering change programs in those days weren’t an option. Self-study materials worked for some, but educational materials alone weren’t enough to engage most employees in lasting changes in unhealthy habits like smoking, inactivity and poor eating.
As we pondered this challenge, one of us asked, “Why couldn’t we just call them?” It was an intriguing idea but raised many questions. Who would we call? How would we get permission to call them? Would they answer or agree to work with us? Who would make the calls? What would we do on the calls? How would we keep track of them? What data would we need? How would we measure success? This final question was particularly salient, since I wasn’t convinced these telephonic behavior change programs would work or be cost-effective.
Several of our clients were interested in our idea and offered to work with us, so we began developing initial answers to our many questions. We began pilot testing with four health educators (we didn’t call them coaches back then) who called individuals with significant health risk profiles to see if they could help them change. They conducted a series of 5-7 calls with participants over a 12-24 month period to test the effects of call “dose” and program duration. While this simple beginning was only rudimentarily informed by the behavior change science of the time, it established a foundation to begin collecting qualitative and quantitative data to figure out what was and wasn’t working to make it better.
Fortunately, this was 1992 and people almost always answered their phones! Many thought it was great that a health educator would actually call offering help, so initial engagement was quite high and about 80 percent of participants completed their programs. Our coaches had many successes, but we discovered we had a lot to learn about helping participants change. Unfortunately, the onsite group programs and self-study materials of that era were curricular and focused on immediate action – making and executing a plan to quit smoking, start exercising, eat healthier – and most participants just didn’t fit into that neat little behavioral box.
The reality was that participants were all over the map. Some were ready, willing and able to change – and they were eager to enlist the coach’s help. But most weren’t quite ready just yet, weren’t sure it was worth the effort, or didn’t know what to do. To be most effective, coaching needed to be personalized to this diversity of needs. Looking to behavioral science and what we were learning from participants to shape our coaching model, we quickly recognized that Prochaska’s Transtheoretical Model gave our coaches a powerful framework for identifying and responding to each participant’s personal readiness to change. We trained our coaches to assess “stage of change” during each call and to use this information to focus the call on the most helpful change processes for this point in the participant’s change journey.
The TTM is a great framework for change, but it didn’t give our coaches all the skills they needed for the job. Most had great content knowledge in their health field (e.g., exercise physiology, nutrition, nursing) but our participants needed help in a personal change journey. The coach’s role in that process was to be a behavior change facilitator and collaborator. We discovered the best coaches were empathetic and great listeners, so these became important hiring criteria. Willingness to do the work of change also requires ongoing commitment, so we trained our coaches in motivational interviewing techniques to help them work with the many participants ambivalent about making change. We also created an ongoing in-service training and peer review process that helped our coaches to learn from each other.
As coaches collaborated with participants, we learned that specific changes were interconnected and deeply entangled in the participant’s life. Sometimes participants who came to us to quit smoking needed to learn stress management skills or how to manage their weight in order to succeed in their smoking quit attempt. Many participants wanted to make multiple changes, and we learned not to discourage this. We increasingly took a whole-person approach to our coaching practice to accommodate what we learned about how participants change. Building trust between participant and coach was essential, so we adopted a primary coach model where the same coach made every call.
The telephonic modality we originally worried about turned out to be an asset with many participants. The greater anonymity seemed to help them open up quickly about their challenges. It also facilitated a very task-focused approach that made effective coaching interactions quite short, usually no more than 15 minutes after the first call. This would make one-on-one coaching a cost-effective approach – assuming it actually worked.
While participant feedback showed that most of them loved working with our coaches and initiated changes during the program, the bottom line was whether they made sustained behavior changes that led to reduced health risks. We conducted a large peer-reviewed study that answered this question. Participants made long-term changes in their primary health behavior issue and in secondary health issues as well. These results validated the effectiveness of our coaching model and the efficacy of our whole-person approach, demonstrating very clearly that a well-designed coaching program delivered by trained, skilled coaches could move the needle on health.
Of course, times change and past approaches to engaging participants in coaching programs and completing a series of voice interactions have become less effective. The advent of the Smartphone and other devices has changed all the rules about how people engage, interact and manage their lives and relationships. While these evolving technologies create challenges, they also create new opportunities for increasing coaching effectiveness, efficiency and scale. This exciting new era that I’m calling telecoaching will be the focus of my next blog.
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