Group health coaching: strengths, challenges, and next steps.

There is great need for cost effective approaches to increase patient engagement and improve health and well-being. Health and wellness coaching has recently demonstrated great promise, but the majority of studies to date have focused on individual coaching (ie, one coach with one client). Newer initiatives are bringing a group coaching model from corporate leadership development and educational settings into the healthcare arena. A group approach potentially increases cost-effective access to a larger number of clients and brings the possible additional benefit of group support. This article highlights some of the group coaching approaches currently being conducted across the United States. The group coaching interventions included in this overview are offered by a variety of academic and private sector institutions, use both telephonic and in-person coaching, and are facilitated by professionally trained health and wellness coaches as well as trained peer coaches. Strengths and challenges experienced in these efforts are summarized, as are recommendations to address those challenges. A working definition of "Group Health and Wellness Coaching" is proposed, and important next steps for research and for the training of group coaches are presented.

INTRODUCTION

There is an urgent need for new approaches to decrease patient suffering, disability, and premature death, as well as skyrocketing healthcare costs. The importance of improved patient engagement has become increasing apparent, as lifestyle behaviors are a major factor in at least 80% of chronic disease. Health and wellness coaching has been proposed as one approach to empower individuals to make choices that will improve their health and well-being. Group models would likely increase the availability, access, and potential population impact of coaching.

The past decade has seen a dramatic increase in the amount of research conducted on health and wellness coaching (“health coaching” in this article). Early research on programs that incorporate health coaching has demonstrated impressive results in the prevention of cardiovascular disease, diabetes and stroke,, obesity, weight-loss maintenance, and cancer. Peer coaching also has shown great promise in promoting health behavior change. Most of these trials, however, included coaching in an individual format: one coach with one client. The potential value of coaching in a group format requires further exploration.

Why Focus On Group Health Coaching?

Group health coaching (referred to as “group coaching”) is in its infancy, and well-designed studies are needed to determine the degree to which it is efficacious and cost effective. However, a glimpse of the potential contribution of group coaching comes not only from the studies presented in this article but also from the wealth of outcomes studies of group therapy. Multiple reviews have demonstrated that group therapy is a cost-effective and beneficial treatment.

High-quality group therapy offers benefits that may yet be demonstrated in group coaching. Such benefits (ie, “therapeutic factors”) include a sense of “universality” as group members share their common struggles and a sense of altruism derived from group members helping each other. Members of a cohesive group often experience a sense of belongingness and esprit de corps, which may empower individual group members to make positive changes. Add to that the instillation of hope and boost to self-efficacy that can be gained from seeing similar individuals make positive changes., In addition, in situations in which assimilating new information is helpful, groups offer an avenue for didactic instruction to be interwoven into the process.

Finally, while not to deny the importance of individual health coaching, group coaching offers the potential for cost savings and greater reach. Group coaching may provide a more realistic and readily available option for coaching across the population, increasing the reach of coaching in a more sustainable way than would individual coaching alone.

The purpose of this paper is to spotlight a selection of group coaching interventions currently underway or very recently concluded. Many of the strengths of group coaching services are presented, as are some of the challenges faced in these interventions and suggestions for addressing those challenges. Finally, a working definition of group coaching is proposed, as are important next steps in terms of research and training of group coaches.

Descriptions of the Coaching Teams and Featured Group Coaching Projects

Faculty and staff members of eight coaching teams from institutions throughout the United States contributed to the formulation of this article. The contributing teams and the centers they represent are presented in Table 1. The diversity of the faculty and staff listed in this table highlights the field's multidisciplinary nature. Seven of these teams contributed a description of an ongoing or recently completed group coaching project, and these descriptions are presented in the Appendix. The task of synthesizing this information was led by faculty on the eighth team: the health coaching program at Vanderbilt University Medical Center.

Table 1

Faculty and Primary Health Coaches for the Teams Contributing to This Article

Coaching Team	Centers Involved	Primary Faculty and Coaching Staff
Vanderbilt University Health Coaching Program	Vanderbilt Center for Integrative Health and Vanderbilt Dayani Center for Health and Wellness; Vanderbilt University Medical Center	Roy Elam, III, MD; Blaire Morris, ANP-BC, CPHWC; Linda Manning, PhD, CPHWC; Zack Klint, MS; Abby Cooper, MHIM; Lesa Abney, RN-BC, CPHWC; Colin Armstrong, PhD, CPHWC
Abbot Northwestern Hospital Coaching Team	Penny George Institute for Health and Healing	Susan Masemer, MS; Molly Ellefson, MS, CHWC; Mary Farrell, MS, PCC; Barbara Hopperstad, MA, CHWC; Barb Brower, RD, CTC
Duke Integrative Medicine Clinical Integrative Health Coach Team	Duke Integrative Primary Care	Linda Duda, MSW, PCC; Julie Kosey, MS, PCC; Annie Nedrow, MD, MBA; Cathy Parham, MBA, PCC; Melva Strait, RN; Jessica Wakefield, MA, LPC; Ruth Q. Wolever, PhD
Harvard Vanguard Medical Associates Health Coaching Workshop	Departments of Internal Medicine, Watertown and Cambridge practices	Heidi Duskey, MA, CWC; Ashley Norwood, BA, CWC
Medica Health and Wellness Coaching		Chelsea Anderson, MSW; Lynne Fredrickson, BS; Barb Schnichels, MSSW, LICSW; Mark Brandenburg, MA, CPCC; Holly Link, MA, MFT
Spaulding Rehabilitation Hospital Stroke Center	Department of Physical Medicine and RehabilitationHarvard Medical School	Elizabeth Pegg Frates, MD; Lynne Brady Wagner
Take Courage Coaching		Rebecca Curtis, ACC; Lisa Creekmur, RN-NC, CPHWC; Kendy Anderson; Shelley Garretson; Beth Jackson, RN
University of Minnesota (UMN) and Gustavus Adolphus College (GAC)	Gustavus Well-being Initiative and the Center for Spirituality and Healing (UMN)	UMN: Karen Lawson, MD; Becky Gorman, PA; Jayne Sommers, MA (doctoral student) GAC: Stephen Bennett, PsyD, LP; Judy Douglas, MS; Heather Dale, PA-C; Lisa Rinehart, MS, LMFT

Table 2 summarizes the primary characteristics of the seven coaching interventions featured in this article. These interventions included group coaching provided in person, via telephone, a combination of the two, or client choice among those options. In the coaching program that allowed individuals a choice between in-person and telephonic coaching (Duke Integrative Medicine), clients strongly preferred in-person coaching, although previous programs have shown the opposite. Most of these interventions are facilitated by professionally trained health coaches, though trained peers act as coaching facilitators in one intervention (UMN/ GAC) and a combination of professional and peer coaches is used in another (Take Courage Coaching). Finally, as shown in Table 2, there is a great deal of variability in the number of coaching hours provided in these interventions. The most time-intensive intervention (Take Courage Coaching) focuses on clients who are disabled by chronic pain and associated factors (eg, opioid abuse/dependence), a particularly challenging and costly condition to address.

Table 2

Characteristics of the Featured Group Coaching Interventions

Coaching Program	Type of Institution	Health Issues Targeted	Coaching Route	Coaching Provider	Individual Coaching Hours (h)	Group Coaching Hours (h)
Abbot Northwestern Hospital	Nonprofit hospital, medical fitness center	General health and well-being, stress	In person	Professional coaches	0	4
Duke Integrative Medicine	Academic medical center	Mixed chronic medical conditions	Choice of in person or telephonic	Professional coaches	0	7.5
Harvard Vanguard Medical Associates	Nonprofit medical group	Mixed chronic medical conditions	In person	Professional coaches	0	Group 1: 6Group 2: 12
Medica Health and Wellness Coaching	Health plan	Mixed chronic medical conditions, stress	Telephonic	Professional coaches	2	8
Spaulding Rehabilitation Hospital/Harvard	Academic medical center	Stroke survivors and caregivers	In person	Professional coaches	0	6
Take Courage Coaching	Private pain management coaching corporation	Chronic pain, mixed precipitating conditions	Telephonic	Professional and trained peer coaches	27	52
University of Minnesota and Gustavus Adolphus College	Collaboration between a state university and 4-y private liberal arts college	General health and well-being, stress	In person, with occasional phone meetings	Trained peer coaches	0	Faculty: unlimited Student: 8

DISCUSSION

Several of the coauthors of this article contributed their viewpoints with regard to the strengths of group coaching as well as the challenges they experienced providing these interventions. What follows is a summary of those strengths and challenges, as well as suggestions for addressing the challenges.

Strengths of Group Coaching

A “sense of community” afforded by group coaching was identified as a primary strength of this approach. When individuals make commitments toward their goals in front of the group, they feel a greater sense of responsibility to follow through. They also feel less alone and are often open to learning from other clients' experiences. For example, a discussion of clients' “reasons for change” may spark group members to identify additional reasons to make their own changes. Clients are able to observe the myriad ways that individuals try out new behaviors in the learning process, amend their behaviors, and retry. This variety of approaches can encourage creativity and provide the courage to try something new. Courage and willingness to try new things that inherently have a greater risk of failure are further augmented by a supportive “let's explore this together” tone of a group.

As with all coaching, nonjudgmental communication and strength-based focus are two critical elements of group coaching. These elements allow clients to experience empowerment and try new things with less fear. Clients from the UMN/GAC project explicitly mentioned such issues in their program feedback, including the statements, “I loved to see a focus on strengths and positive types of change” and “The power of authentic communication [and] support without fixing is a good way to be.”

Coaching in a group format also allows for streamlined education. If appropriate, coaches can offer content education to enhance knowledge as well as teach skills in a more efficient manner than in individual coaching. Learning and practicing new things together further strengthens the group bond. The educational efficiency may provide a more realistic and sustainable way to increase the reach of coaching. Whether in person or by phone or via the Internet, a single well-trained health coach can potentially have a positive impact on numerous clients simultaneously. Training peer facilitators to lead groups could further increase the reach of such interventions. Group coaching, whether provided by professionals or by trained peers, may offer a method to reach larger numbers of clients with fewer staff members. It should be noted, however, that while randomized controlled trials of individual coaching have begun to show the value of such services, it is premature to say the same for group coaching (see “Next Steps”).

Challenges Reported in Group Coaching

Two major types of challenges in providing group coaching were identified: challenges with logistics (eg, client recruitment and scheduling) and challenges associated with managing group dynamics.

Logistical Challenges.

While group coaching can reach large numbers of individuals simultaneously, it can be undermined by recruitment and scheduling issues. The group models presented in this article require all interested clients to be available “live” at the same time—whether in person or via phone. Therefore, an adequate number of individuals need to be both ready to make changes in their lives and consistently available at the same day and time. One partial solution to this challenge currently being evaluated at UMN/GAC is to hold “open groups” in which rolling enrollment allows members to join as soon as they are ready. Open groups are common in healthcare. Support groups typically are conducted in open formats, and probably the most well-known open approach is that of 12-step programs such as Alcoholics Anonymous and Narcotics Anonymous.

However, there are two potential drawbacks to open groups. First, even with great care, “newcomers” may not feel on equal footing with those who have been attending the group for weeks or months. Some newcomers may be comforted to see longstanding group members greet each other with first names and hugs, while others may feel more like guests or outsiders. Second, since group membership changes over time, group dynamics can shift, making cohesion more difficult to maintain. Effective group facilitation in open formats requires skilled group leaders who can create an atmosphere in which newcomers feel welcome and returning members continue to feel supported and valued.

All but one of the interventions described in this paper are delivered through a “fixed start date” or “closed” group format, which also has pros and cons. Closed groups, in which all clients begin and end the group together, benefit from allowing members to gradually bond as they face challenges, learn together, and share in the common journey as the group progresses. One downside is that clients may have to wait some period of time for the start of the next group. One solution is to offer multiple groups with start dates staggered throughout the year so clients don't have to wait as long to get started. Individual coaching also can be used to fill the gap between when a client expresses an interest in change and the start of the next group.

Challenges associated With managing Group dynamics.

As with any group, coaching groups typically involve a mixture of quieter, more introverted individuals and more extroverted individuals. Well-trained coaches can manage this mix by drawing out quieter clients and redirecting talkative ones. In addition, it is useful to clearly communicate group guidelines early on (eg, the importance of clients respecting each other's time to talk and not trying to force solutions upon their fellow group members). One of the group programs described in this article had the members create their own guidelines during the first meeting, providing an initial experience that builds group cohesion and buy-in to the guidelines. In using that approach, coaches can shape and augment the guidelines generated by the group. If, for example, group members don't bring forth the idea of “sharing the floor,” then the coach can propose that an important guideline would be to allow all individuals time to share.

Typically, group members do not respond well to their fellow clients telling them what they “should” do, “have to” do, or “need to” do. Clients almost always note that they don't want to be given unsolicited advice. Again, such advice giving can be minimized by involving members in explicitly setting up group guidelines in the first session. Once guidelines are in place, it is seamless for the coach to refer to them if a client begins offering advice. This further ensures the primary tone of the group: that of nonjudgment and a focus on strengths.

Multiple contributors to this article noted that group coaching is not for everyone. Some individuals may not feel comfortable or empowered in a group setting, and others may be disruptive (eg, by monopolizing sessions or by repeatedly bringing up issues better addressed within individual or group therapy). Individual interviewing and prescreening of clients prior to the start of the group may help, although this adds to program costs. If prescreening of clients is conducted, inclusion and exclusion criteria should be identified in advance, with clear referral pathways in place for those who might be better served by individual coaching, a support group, the services of a mental health professional, or for a combination of those options. And, even with prescreening, the coach should remain prepared for clients sharing issues during the course of group coaching that may require referral, as it is common for such issues to come up only after trust has been established or as clients develop new insights and/or experience setbacks.

Given the challenges seen in managing group dynamics, professional group coaches not only require training in health coaching skills but also in skills specific to group facilitation, such as how to: (1) encourage forward momentum in the group setting; (2) monitor group participation, ensuring adequate time for all; (3) draw out individuals who process issues internally before speaking; (4) encourage participation without making uncomfortable those individuals who may be more reserved; (5) quickly modulate potentially disruptive behavior before it harms group cohesion while at the same time effectively addressing the needs of the disruptive client; and (6) celebrate the forward progress of group members while remaining sensitive to those who may be “stuck.” A peer coaching facilitator needs some level of instruction and support with these same skill sets, although with different expectations around level of competency. All of this is to say that prescreening, inclusion and exclusion criteria, and clear referral pathways in no way negate the need for solid group facilitation skills.

Next steps for Group Coaching

As group coaching is now in its infancy, work is needed in multiple areas. Below are recommendations in three areas: definition/delineation of group coaching, research, and training.

Clear definition of Group Coaching and delineation From Related services.

Although outcomes research is a high priority, group coaching interventions must first be consistently defined and well-described. For example, what are the factors that clearly delineate group coaching from group therapy, support, or education? Likely, these will not be mutually exclusive group types, as coaching groups may include some aspects of education, skills building, peer support, and so on. Given the need for clear definitions, we propose the working definition of “Group Health and Wellness Coaching” presented in the Sidebar. Readers who are interested in the general roles of peer coaches are encouraged to read the overview by Thorn et al.

Needed Research.

Research is needed on many aspects of group coaching to determine the degree to which it is effective and economical. First, there is a particular need for randomized control trials comparing participants in group coaching to those in four different conditions: waiting controls, those receiving individual coaching, those in group education, and those in support groups. The latter two are needed to demonstrate the extent to which coaching may be a key ingredient that leads to improvements over and above the impact of increased knowledge or social support. Second, studies are needed to compare in-person, phone, and video chat–based routes. Third, the economic argument for group coaching must be empirically evaluated with cost-effectiveness studies. Fourth, research is needed to determine which client characteristics and health issues are best suited for group coaching. Finally, outcome evaluations are needed to examine the impact of group size, session length, frequency, and intervention duration.

Coaching is provided in a small group format (eg, 4-20 participants).

The group facilitator is a professional health and wellness coach who has been trained, mentored, or supervised in the delivery of group coaching services.

While the group sessions may include experiential exercises, education, or instruction in techniques, the focus is predominantly on coaching rather than support, education, instruction, or therapy.

Typically, more than one client is coached during a given group session.

Modeled by the facilitator, all group members learn to “provide encouragement/affirmation, focus on positive progress (no matter how small), a nonjudgmental stance throughout the exploration, rapport-building through personal chat, and reflective listening to confirm accuracy of the listeners' understanding and overlaps in speech.”

Each group participant is viewed as the expert in his or her own life and either has or can develop the internal resources required to direct desired change. Guided by the coach—through deep listening, thoughtful reflections, and evocative questions—the group provides a safe, nonjudgmental space allowing for creative exploration to support individuals in determining their own goals and action plans, developing intrinsic motivation, using their strengths, and increasing self-efficacy for initiating and adhering to healthy changes as they move toward optimizing their health or well-being.

Creative group brainstorming may occur if a participant requests help in idea generation, and always with a focus on positive progress and a harvesting of lessons learned and shared.

Group health and wellness coaching can be delivered in-person or at a distance (phone bridge, webinar, group video chat). Sessions typically are 60 to 90 minutes and can also be delivered in a multi-hour, all-day, or multi-day workshop. Program duration could range from one session to multiple sessions over weeks or months or could be a continuous program with weekly, biweekly, or monthly sessions over the course of 1 year or longer.

Standards of Training.

As with the entire field of health coaching,, much work is needed to determine the educational standards, key obligatory competencies, and best practices for group coaches. It is our belief that group coaches require specialized training that includes a knowledge base and skills specific to group facilitation. Training should include trainee opportunities to observe and then be observed by experienced group coaches using different routes (eg, in-person, telephonic, and video conferencing). Based upon accepted training standards, specialty training in the provision of group coaching should occur after and build upon appropriate training and experience in individual health coaching. In addition to it being an accepted standard that specialty training follow general training, it also is common sense: If a coach does not possess the skills to coach an individual in making progress, it seems unlikely he or she could do so with an entire group of individuals simultaneously. Finally, the development of successful models for group coaching should be informed by the decades of research available with other types of group intervention (eg, group therapy, group education, support groups, group work in organizational development).

CONCLUSION

Health coaching holds promise as a relatively new intervention that may help individuals improve their ability to prevent and manage chronic illness and optimize long-term well-being. Given the relatively limited number of professionally trained health coaches available in this new profession, group coaching may be a way to leverage both the services of coaches and the innate power of humans to help themselves and others. Many questions remain, but group coaching to support positive change and improve patient engagement may have the potential to diminish suffering, improve well-being, and save significant public and private resources.