ResearchBrief

2021

Behavioral HealthCoaching

ResearchBrief

2021

Behavioral HealthCoaching

Content

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Behavioral Health Coaching

An Action-Oriented Approach to Mental Health Support

The Ginger Model

Conclusion

Appendix

Executive Summary

Introduction

Ginger Coaches

The Origins and Development of Coaching

Coaching, Psychology, and Therapy

Therapy Tools Appliedto Coaching

Virtual and Text-Based Mental Health Care

Summary ofKey Coaching Research

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Executive Summary

Introduction

It is well documented that mental health is a grow-ing public health crisis, exacerbated by the multifactorial strain from COVID-19.1) As of April 2020, one out of four U.S. adults meet the criteria for serious mental distress, eight times more than a demographically similar sample from 2018.2) In October 2020, Mental Health America published data showing a 93% increase in people seeking anxiety support and a 62% increase in people seeking depression support since 2019.3) Of the more than 1.5 million people included in this survey, 61% had never received any form of mental health treatment or support prior to 2020.

This increasing need for mental health care is out-pacing the number of licensed mental health providers. There is a growing recognition that we can only meet this demand through new care delivery models, including the expansion of tele-health to overcome the geographically uneven distribution

• The origins and development of the coaching field

• How coaching relates to therapy and applies common psychotherapy tools

• The evidence base showing that coaching and text-based interventions can lead to improved mental health

• How Ginger applies the science of coaching in its on-demand mental health system

This brief provides an over-view of coaching in the field of mental health.

What You’ll Learn

Virtual and Text-Based Mental Health Care

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of providers and by developing new labor pools to overcome the shortage in licensed providers.4) Numerous studies have shown promising results around delivery of mental healthcare through behavioral health coaches working in collaboration with licensed clinicians. This brief evaluates the mechanisms of action and efficacy of behavioral health coaching for mental health conditions/disorders, associated symptoms, and health concerns. Additionally, it describes how Ginger, an on-demand virtual mental health company, implements coaching to pro-vide high-quality mental health support to its members.

The Origins and Development of CoachingWhile the roots of coaching date back

to classical Greece, the field and methodology of coaching psychology formally developed in the ear-ly 20th century via sports psychology research.5)

6) Health coaching in particular has emerged as a potential solution to traditional provider shortages. Health coaches work to motivate patients to make lifestyle behavior changes, adhere to medication regimens, respond to medical requests schedule and attend appointments, and improve their quality of life in the context of managing various health con-ditions, including diabetes, heart disease, cancer, autoimmune conditions, among others.

A challenge for the field has been standard-izing definitions and accreditations. Several industry organizations have emerged to address these gaps in the field of coaching and within health coaching specifically. The International Coach Federation (ICF) defines coaching as “partnering with clients in a thought-provoking and creative process that inspires them to maximize their personal and professional potential.”7) The National Board for Health and Well-ness Coaching (NBHWC) defines the scope of practice of health and wellness coaches to be to “work with individuals and groups in a client-centered process

to facilitate and empower the client to develop and achieve self-determined goals related to health and wellness. Coaches support clients in mobilizing in-ternal strengths and external resources, and in de-veloping self-management strategies for making sustainable, healthy lifestyle, behavior changes.”8)

To support the legitimacy of health coaches, the ICF and the NBHWC have both created creden-tialing requirements. The ICF offers three different credential levels with the following requirements: completion of at least a 60-200-hour ICF approved coaching program, 100-2,500 hours of coaching ex-perience with 8-35 different clients within a 24-month period; at least 10 hours of coach mentorship; and completion of the Coach Knowledge Assessment.9) To be certified through the NBHWC, coaches must complete an approved training program, at least 50 health and wellness coaching sessions, in addition to passing their National Board Certification Exam.10) Recognizing the value of coaching, and the unique expertise it requires the American Medical Associa-tion (AMA) announced approval of new Category III Current Procedural Terminology (CPT®) Codes for health and well-being coaching effective January 1, 2020.11)

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Coaching, Psychology, and TherapyDespite some lack of agreement

around whether coaching psychology and coaching are distinct modalities, there is gener-al consensus that coaching focuses on behavior change through goals as opposed to focusing on diagnosis or pathology.12) 13) 14) 15) 16) 17) 18) 19) Research supports the use of psychology models among trained coaches and the application of psycho-logical methods in working with both clinical and non-clinical populations.20) 21)

Within coaching, there is often a dis-tinction between performance or behavioral coach-ing versus developmental coaching, with the latter aligning more with the use of psychological mod-

els and tools. Performance or behavioral coach-ing is focused on actions, behaviors, and goal achievement based on a time frame and action plan to which the coach holds the client account-able to. Developmental coaching , on the other hand, focuses on the client’s mindset, emotions, beliefs, and personality, seeking inner change to affect outer circumstances or performance outcomes.22) 23) 24) 25) 26) 27) 28) In the Ginger System, behavioral health or emotional wellness coaches combine goals-work with developmental coach-ing to help members improve their mental health, take accountability for their thoughts and emo-tions, and take action steps to improve self-care and emotional wellness.

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Summary of Tools Applied to Coaching

Tool Description How It’s Applied to Coaching

Positive Psychology

Solution- Focused Brief Therapy

Acceptance and Commit-ment Therapy

Focusing on client’s strengths; focus-ing in sessions on a positive “diagno-sis” (i.e. what is going well for the client); helping the client set “optimal functioning” goals; using positive psychology interventions such as gratitude; and assessing positive qualities and strengths of the client as a means of developing resilience.30)

SMART goals development, grati-tude practices, strengths explora-tion, values practices, and previous success exploration.

Mindfulness skills training and pro-

motion of psychological flexibility.

Move away from a focus on dysfunction and disorder to more “positive” aspects of human functioning such as “positive emotions” and psychological development.29)

Future-oriented, goals-focused, positive psychology form of therapy, focused on solutions instead of problems.

Finding acceptance for challenges.

Therapy Tools Appliedto Coaching

While coaches do not treat complex psychological disor-ders, they support emotion management, challenge support rela-tionships and communication skill-building, and apply tools to re-duce stress, anxiety, and depression. Behavioral health coaches and therapists use similar evidence-based tools to support emo-tional health and help members through anxiety and depression.

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Dialectical Behavior Therapy

Motivational Interviewing

Cognitive Behavioral Therapy (CBT)

Mindfulness- Based Stress Reduction

Psycho- education

Behavioral Activation

Skills training in mindfulness, inter-personal effectiveness, emotional regulation, and distress tolerance.

Using open-ended questions and reflective listening to help clients express their concerns about change, which coaches can use to help individuals set goals and determine a plan that matches their readiness for change. 33) 34) 35) 36)

Supporting thought journaling and reframing of cognitive distortions.

Supporting breath-work, meditation practices, and mindful awareness practices.

Ensuring basic competence, supporting self-responsibility and empowerment, improving insight into the conditions that prevent the desired state, promoting relapse prevention, and supporting broad-er health.37)

Activity monitoring, assessment of life goals and values, activity scheduling, skills training, relax-ation training, contingency man-agement, procedures targeting verbal behavior, and procedures targeting avoidance.38)

Developed from behavioral and social learning theories for treatment of clinical suicidal populations, with expanded use in clinical populations at risk for suicide and self-harming behaviors such as personality disorders, depression, multiple anxiety disorders, eating disorders, and substance abuse disorders. 31)

Developed for addiction counseling in the 1980s as a way to help clients change their behavior in stages and resolve ambivalence.32)

Helps clients learn to examine thoughts using a structured approach in order to develop more rational, logical, and constructive thoughts that improve emotions and behaviors.

Development of present- moment attention and non-judgmental awareness of thoughts and emotions.

Combining therapeutic interventions with education about the diagnosis, health issue, treatment options or client concerns.

A CBT skill used in treating depression that supports an understanding of how behavior influences emotions.

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Virtual and Text-Based Mental Health Care

A large body of evidence supports the effectiveness of both telemedicine and tex-ting modalities to improve mental health out-comes. A 2017 study found that off-site, tele-medicine-based, collaborative care led to better outcomes versus in-person collaborative care.39) General advantages of telemedicine include im-proved access, flexibility, and interactivity, and reduced costs.40)

In addition to telehealth, mo-bile-based interventions have also become in-creasingly common as 81% of Americans own a

smartphone.41) A 2017 meta-analysis of smart-phone-based treatments concluded that they are promising for depression management.42) Several studies have also shown that inclusion of a human supportive layer in virtual care im-proves outcomes.43) A 2017 systematic review of synchronous text-based chats found significant and sustained improvements in mental health outcomes following synchronous text-based intervention, and post-treatment improvement was equivalent to that of face-to-face or tele-phone counseling.44)

Ginger’s mission is to create a world where mental health challenges are never an obstacle. By harnessing the power and conve-nience of a smartphone, Ginger is able to provide access to high-qual-ity care to anyone, anywhere, in order to reduce symptoms of stress, anxiety, and depression. Ginger provides individuals with on-de-mand, evidence-based, virtual behavioral health coaching, therapy, and psychiatry, along with self-guided content and assessments. Coaches work with members through a text-based interface, while therapists and psychiatrists meet with members through video ap-pointments. In Ginger’s integrated system, coaches collaborate with the broader Ginger coaching team in addition to therapists and psy-chiatrists to provide the right level of team-based care to members.

The Ginger Model

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Ginger coaches have an advanced degree (Master’s or Doctorate) in a field related to mental health and/or an accredited Coach Certi-fication (such as ICF or NBHWC) in addition to at least two years of experience and six months of direct supervision under a qualified, credentialed, or licensed supervisor. Our coaches come from a wide variety of backgrounds and bring a breadth of experience to the table. They have worked in settings as varied as mental health, child welfare services, residential treatment centers, outpa-tient clinics, VA centers, senior centers, commu-nity health centers, jails and the prison system, nature, non-profits, hospitals, human resource departments, schools, shelters, private practic-

The Ginger model of care operates from the framework that clini-cal care is most effective when paired with coaching. Collabora-tion ensures that the coaching plan aligns with the therapy and/or psychiatry treatment plan, that there is a shared understanding of members’ needs and goals, that progress can be evaluated across different levels of care, and that members can be triaged from one level of care to another as needed.

es, and crisis hotlines. They have served children, adolescents, families, adults, couples, entrepre-neurs, and businesses in their capacities as ther-apists, behavioral health coaches, nutritionists, social workers, physical health coaches, spiritual counselors, vocational rehabilitation counselors, functional medicine practitioners, fitness and yoga instructors, recreation therapists, school teachers, and meditation instructors. Coaches' areas of specialization include managing work-place conflict, motivation, goal setting, anger management, suicidal ideation, domestic vio-lence and abuse, rehabilitation for developmen-tal disabilities, emotional and disordered eating, grief support, relationships, religion and spiritu-ality, sexual identity, crisis and life transition sup-port, positive psychology, and addiction coun-seling. To ensure quality and appropriateness of care, coaches receive weekly direct clinical su-pervision, participate in a weekly group meeting to process challenging cases, and receive feed-back from the clinical team that reviews coach transcripts. Coaches receive ongoing training from licensed or credentialed practitioners in evidence-based coaching practices and thera-py models of care. Ginger’s collaborative model, which teams up professional behavioral health coaches with licensed clinicians, yields signif-icant improvement in anxiety and depression among members.45)

Ginger Coaches

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Conclusion

Although coaching dates back to ancient Greece, only recently has it become a more formalized and recog-nized discipline, particularly in the area of mental health. Or-ganizations like the International Coaching Federation and the National Board for Health and Wellness Coaching have devel-oped definitions and certifications to bolster the credibility of the coaching field. The American Medical Association also recognizes health and wellbeing coaching as a reimbursable service via CPT codes.

To address mental health issues, coaches use many of the same evidence-based tools as therapists; however, they tend to focus on behavior change through goals as opposed to diagnosis or pathology. Systematic reviews have conclud-ed that health coaching can motivate change in chronically ill patients’ lifestyle behavior, leading to improvements in physical and mental health status. Additionally, there is growing evidence that coaching interventions delivered via text have similar effectiveness to traditional in-person care and may offer some additional benefits in improving conve-nience and reducing stigma.

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In Ginger’s virtual on-demand system, coaches collab-orate with the broader Ginger coaching team as well as thera-pists and psychiatrists to provide the right level of team-based care to members. Ginger coaches are mental health subject matter experts with an advanced degree (Master’s or Doc-torate) in a field related to mental health and/or an accredited Coach Certification; in addition, they have at least two years of experience and six months of direct supervision under a quali-fied, credentialed, or licensed supervisor.

As the demand for mental health services continues to grow, it is important that we continue to innovate on new care delivery models while maintaining a high standard for quali-ty and outcomes. To this end, Ginger plans to launch a Train-ing Institute to provide first-in-class telehealth training for coaches and clinicians. By providing care that is collaborative, measurement-based, empirically supported, culturally respon-sive, personalized, on-demand, and AI-enabled, Ginger will continue to pursue its vision of a world where mental health is never an obstacle.

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Appendix

Publication Title

Study Objectives

Key Findings

The Effects Of Health Coaching On Adult Patients With Chronic Diseases: A Systematic Review

Describes the effects of health coaching on adult patients with chronic diseases.

Health coaching is an effec-tive patient education method that can be used to leverage a patient's willingness to change their lifestyle and support their home-based self-care.

Application of Synchronous Text-Based Dialogue Systems in Mental Health Interventions: A Systematic Review

Reviews the current evidence for online one-on-one mental health interventions that use text-based synchronous chat.

Synchronous text-based inter-ventions produce significant and sustained improvements in mental health outcomes.

Does Coaching Work? A Meta-Analysis on the Effects of Coaching on Individual Level Outcomes in an Organizational Context

Meta-analysis of coaching within organizations.

Coaching is an effective inter-vention for employees, yielding significant improvement of performance/skills, well-being, coping, work attitudes, and goal-directed self-regulation.

Summary ofKey Coaching Research

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Appendix

Publication Title

Study Objectives

Key Findings

Enhancing Goal Self-Concordance Through Coaching

A study of 26 senior managers with a comparison of results from receiving coaching support for one goal versus no coaching support for other goals.

Managers were significant-ly more likely to commit and adhere to coached goals versus goals for which they received no coaching support.

Integrative Health Coaching: A Behavior Skills Approach That Improves Hba1c And Pharmacy Claims-Derived Medication Adherence

Observational study of 56 participants receiving coaching calls over six months.

Coaching improves oral medica-tion adherence and psychoso-cial measures including patient activation with confidence for self-management, improved mood, improved quality of life, and positive outlook at health challenges.

Do People With Existing Chronic Conditions Benefit From Telephone Coaching? A Rapid Review

Scoping review of effectiveness of telephone-based coaching services for the management of patients with chronic diseases.

Telephone coaching for people with chronic conditions can improve health behavior, self- efficacy, and health status, espe-cially for members of vulnerable populations who have difficulty accessing health services.

Augmenting Evidence-Based Care With a Texting Mobile Interventionist: A Pilot Randomized Controlled Trial

A three-month pilot random-ized controlled trial of 49 individuals with serious mental illness comparing the mobile interventionist approach as an add-on to assertive community treatment versus treatment alone.

Evidence-based texting inter-ventions can serve a crucial role in supporting continuity of care.

Fundamentals for Future Mobile-Health (mHealth): A Systematic Review of Mobile Phone and Web-Based Text Messaging in Mental Health

Literature review of text mes-saging use in mental healthcare to determine effectiveness and purpose.

Text messaging in mental healthcare may increase treat-ment adherence, symptom surveillance, and patient satis-faction.

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Publication Title

Study Objectives

Key Findings

Digital Mental Health Interventions for Depression, Anxiety, and Enhancement of Psychological Well-Being Among College Students: A Systematic Review

Systematic review of digital mental health interventions for college students that explores improvement in mental health treatment.

Results suggest that digital mental health interventions can be effective for improving depression, anxiety, and psy-chological well-being among college students.

Development of an Internet-Based Support and Coaching Model For Adolescents and Young Adults With ADHD and Autism Spectrum Disorders: A Pilot Study

Observational study of internet chat-based coaching for teen-agers and young adults with autism spectrum disorders and ADHD.

Internet chat coaching was found to increase quality of life and self esteem in participants.

Evaluation of an On-Demand Mental Health System for Depression Symptoms: a Retrospective Observational Study

Analysis of data from 1,662 users of an on-demand mental health system that includes behavioral health coaching, clinical services (therapy and psychiatry), and self-guided content.

Users of the on-demand men-tal health system experienced a reduction in their depres-sion symptoms, as measured through the PHQ-2.

Association Between Virtual Care Modality, Utilization, and Anxiety Outcomes: A Retrospective Observational Study

Analysis of data from 1,611 users of an on-demand mental health system that includes behavioral health coaching, clinical services (therapy and psychiatry), and self-guided content, comparing anxiety outcomes by care modality (coaching, teletherapy and telepsychiatry, and collaborative).

Collaborative care (teletherapy and text-based coaching) was most likely to decrease anxiety.

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Publication Title

Study Objectives

Key Findings

Autonomy Support, Relationship Satisfaction And Goal Focus In The Coach–Coachee Relationship: Which Best Predicts Coaching Success?

Exploratory study of 49 coach–coachee dyads comparing measures for coaching success.

A goals focus in coaching is the largest predictor of coaching success versus coach-coachee relationship or autonomy support.

Positive Psychology: The Science at the Heart of Coaching

A review of the literature on positive psychology and its theoretical application to coaching.

Coaching may increase hap-piness “set points” through goals-work and promotion of fulfillment.

Positive Coaching Psychology: A Case Study In The Hybridization Of Positive Psychology

Perspective review on positive psychology and coaching psy-chology that explores whether the fields are essentially the same; whether positive psychology encompasses coaching; whether coaching encompasses positive psychology; or whether the fields overlap but are different.

Positive psychology and coach-ing psychology draw on a common body of theories and practice which belong to neither field.

Cognitive-Behavioral, Solution-Focused Life Coaching: Enhancing Goal Striving, Well-Being, and Hope

Exploration of outcomes from a 10-week experimental cog-nitive behavioral, solution fo-cused group coaching program for non-clinical populations.

The study supports the use of psychological practices for non-clinical populations. THe coached group had enhanced goal striving, hope, and well-be-ing with use of CBT coaching.

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07 coachfederation.org/core-compe-tencies

08 nbhwc.org/scope-of-practice

09 coachfederation.org/icf-credential

10 nbhwc.org/become-a-board-certi-fied-coach/

11 24-7pressrelease.com/press-re-lease/466893/american-medical-as-sociation-approves-new-catego-ry-iii-cpt-codes-for-coaching

12 doi.org/10.1080/17521882.2013.850106

13 researchgate.net/publica-tion/313707730_Coaching_with_self-determination_in_mind_Using_theory_to_advance_evidence-based_coaching_practice

14 Grant, A. M. (2012). An integrated model of goal-fo-cused coaching: An evidence-based framework for teaching and practice. International Coaching Psychology Review, 7, 146–165.

15 Whitmore, J. (2010). Coaching for performance: Growing human potential and purpose: The principles and practice of coaching and leadership. Nicholas Brealey Publishing.

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18 meylercampbell.com/sites/default/files/icpr_vol2_isse_march_2007.pdf

19 doi.org/10.7453/gahmj.2013.034

20 researchgate.net/profile/Tim-Theeboom/publica-tion/303790697_Coaching_Psy-chology_Research_A_Jour-ney_of_Development_in_Research/links/5bee80b2a6fdcc3a8dd9daa0/Coaching-Psychology-Re-search-A-Journey-of-Develop-ment-in-Research.pdf

21 doi.org/10.1080/17521882.2012.711338

22 sitesbysarah.com/mbwp/Pubs/1993_Barrick_Mount.pdf

23 m.timothy-judge.com/Judge%20and%20Bono%20personali-ty-TF--JAP%20published.pdf

24 pdfs.semanticscholar.org/8bfe/f713a0a7f6d26b085bd954c-392d606aaf9a0.pdf

25 m.timothy-judge.com/Judge,%20Bono,%20Ilies,%20&%20Gerhardt.pdf

26 Mount, M.K., Barrick, M.R. & Stewart, G.L. (1998). Five-factor model of personality and performance in jobs involving interpersonal interactions. Human Performance, 11(2–3), 145–165.

Endnotes

27 Nelson, E., & Hogan, R. (2009). Coaching on the dark side. Interna-tional Coaching Psychology Review, 4(1), 9–21.

28 researchgate.net/publica-tion/227639468_Personality_Mea-sures_as_Predictors_of_Job_Perfor-mance_A_Meta-Analytic_Review

29 doi.org/10.1080/17439760.2015.1137627

30 researchgate.net/publica-tion/336257112_Conceptual_frame-work_for_a_positive_psychology_coaching_practice

31 doi.org/10.1176/appi.psychothera-py.2015.69.2.97

32 Miller, W.R., & Rollnick S. (2012). Motivational interviewing: Helping people change (3rd ed.). Guildford Press.

33 doi.org/10.1007/s11414-013-9381-8

34 doi.org/10.1097/NHH.0000000000000139

35 doi.org/10.1097/JCN.0b013e3181cec6e7

36 doi.org/10.7453/gahmj.2013.037

37 ncbi.nlm.nih.gov/pmc/articles/PMC2683741/

38 doi.org/10.1016/j.cpr.2010.04.001

39 ncbi.nlm.nih.gov/pmc/articles/PMC3816374/

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Endnotes

40 doi.org/10.5455/aim.2017.25.240-246

41 pewresearch.org/internet/fact-sheet/mobile/

42 doi.org/10.1002/wps.20472

43 publish.csiro.au/AH/pdf/AH13005

44 doi.org/10.2196/jmir.7023.

45 doi.org/10.2196/17902preprints.jmir.org/preprint/24662

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Imprint

About

Publisher Ginger.com 116 New Montgomery St, Ste 500 San Francisco, CA 94105

January 31 2021

Ginger brings high-quality mental health support within sec-onds to those in need. Through the Ginger app, mem-bers can connect with our team of coaches via text, 24/7, 365 days a year. For those in need of additional support, a therapist or psychiatrist can be added to their care team for video sessions. Over half a million people have access to the Ginger on-demand mental health system through our work with employers, health plans, and other partners.

To learn more about how Ginger can support your workforce, contact us at ginger.com/contact.

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ginger.com