Coaching Patients, Reinventing Therapists

There’s no better Rorschach than a cocktail party, and sometimes Sandra Nahan can’t help but perform a little behavioral experiment amid the small talk and hors d’oeuvres. When strangers pose that ice-breaking inquiry, “So what do you do?” she chooses from the pair of responses that apply and watches the response.

“When I say that I’m a psychologist, it’s: ‘Oh, that’s nice.’ Then they are off to get something to eat--quickly,” Nahan says with a laugh. In her eight years as a clinical psychologist and marriage and family therapist, with a practice in Encino and Beverly Hills, she has grown accustomed to the quick retreat.

But almost a year ago, she decided to augment her practice by training to become a “life coach,” joining the amorphous and burgeoning profession devoted to “helping people reach their dreams.” Adding “coach” to her shingle, stationery and cocktail party shorthand had a measurable social effect. “If I say that I’m a coach, it’s: ‘Oh, really!’ [People] step toward me. ‘ I’ve been wanting to do that!”’

It doesn’t take extreme powers of intuition to read the grays in those sharply contrasting responses. “Language is powerful,” says Nahan, and so is perception. “In therapy, you’re dealing with somebody who is hurting or grieving. Right away you’re coming in at a deficit. With coaching, it’s: ‘You’re good enough to make the team.’ So [clients are] coming in with a skill set, and we’re just trying to sharpen it.” The implication: Coaches shape potential winners; therapists deal with the rest.

As a caregiver, Nahan found it both enticing and freeing to see that simply by repackaging herself, she could continue to provide guidance to people--but without the frustrations, blocks and limits that have pushed nearly a quarter of mental health care practitioners to look for a way out of the profession.

An October 2000 survey published by Psychotherapy Finances, a monthly newsletter targeted to behavioral health care professionals, found that 23% of clinicians are taking active steps to leave their practices. That finding confirmed the perception that the industry has long felt hamstrung by the dictates of a health care system that asks therapists to do ever more paperwork, accept lower fees and make their care plans conform to HMOs’ limits.

Even more telling was the finding that roughly 20% of practitioners are now listing coaching along with their therapy practice’s offerings. Training programs aimed at transforming beleaguered therapists into reinvigorated coaches are proliferating as therapists feel the pull toward coaching’s high-paying, largely unregulated world. Some even venture to say that coaching--with its emphasis on addressing the present rather than long journeys into the past--is the new face of therapy.

At least so far, coaching hasn’t eclipsed the behavioral therapy work Nahan does, but complements it. She has two completely separate practices--one dedicated to therapy, the other focused entirely on coaching.

“When I put on my therapist hat, I’m more concerned with the underlying factors--medical background, family of origin, all-or-nothing thinking, low self-esteem,” she explains. “But when I put on my coaching hat--the person is [already] at the level of being ready, willing and able. In coaching, the goals are clear-cut. It’s action-oriented. It’s over the phone. There is something wonderfully efficient about it.”

A certain breathless optimism sets in when therapists like Nahan describe the possibilities they see in coaching. Indeed, “personal coaching” has become the subject of stories strikingly similar to those that hyped the Internet during its early years. You make the rules. You select the people you work with. And you make big money.

While psychiatrists might charge $250 for an hourlong session and psychologists and marriage and family therapists between $90 and $125, personal coaches, with one year of coach training, can charge between $150 to $350 for three or four half-hour phone sessions a month, says Bobette Reeder, president of the International Coaching Federation. More experienced coaches can charge between $350 and $500 for three such sessions. That can work out to more than $300 per hour, and high-profile coaches can gross anywhere between $100,000 to $200,000 annually. Testimonials abound from those who had tried their hands at other careers--teachers, attorneys, flight attendants--and are reinventing themselves at the same time they are guiding their clients to do the same.

Many coaches describe their process as “active questioning/active listening”--posing questions that require the subjects to see themselves, and life at the moment, in sharp relief. Goals and dreams are the talking points, and it is the coach’s role to help clients to articulate what blocks them from getting there. Instead of an invitation to dust off the past, ideally coaching is a conversation that brings the future into view.

“You don’t have to be broken to find a coach,” says Gale Denning-Mailloux, a therapist and coach who runs the Bonsall Counseling Center and Here-to-There Professional Life Coaching in Bonsall, Calif. “I’m not there to tell you what to do. I’m just there to help someone to see their own vision and learn, ‘This is what I really want to do.”’

For some clients, the goal might be to complete one set project: organizing one’s finances, purchasing a house. Others ask coaches to help them develop a plan that might involve everything from prioritizing their date books to counseling their support staffs and loved ones, which is what David Bach’s coach, Shirley Anderson, provided for him.

“She coached me through a complete life transition,” says David Bach, author of “Smart Couples Finish Rich.” “Going through the exercises with her, I came to the conclusion that I had to let go of my financial planning business.” He relocated from San Francisco to New York and decided to pursue a writing and television career, guided by Anderson all the way. Not infrequently, personal coaching produces clients who themselves decide to enter the field--which Entrepreneur magazine describes as one of the fastest-growing new business categories in America--with more than 10,000 coaches in the arena, up from 1,000 in 1995. If people without a therapist’s training can make it big counseling people toward their goals, it’s no wonder that those with actual counseling credentials see a place for themselves in this booming, high-energy field.

Personal coaching is still largely uncharted territory and still open to fierce debate, largely because the coaching trade--despite its high profile and dramatic proliferation--has largely escaped mandatory government regulation and certification (although there are industry-recognized certification programs offered and still others in the works).

In part, that may be because the concept of coaching seems so nonthreatening and familiar. Over the years, it’s taken on many different monikers--mentor, advisor, consultant, life planner. The most familiar turn on the coach/athlete model is the executive coach who helps turn multimillionaires into multibillionaires. Thomas J. Leonard, a former financial planner and tax accountant, is credited with popularizing “life planning”--now “personal coaching”--for everyday people.

The founder of the virtual campus Coach U and now head of CoachVille, the largest network of coaching resources and support products, Leonard hit on the notion of personal coaching in the late ‘80s, when a couple he’d been advising on their finances altered the drift of their conversation. “They began to ask: ‘What about our lives?’ They were talking about ideas. They were thinking about getting a new car. ‘What color BMW? We just thought you might have an opinion.”’ He found that the notion of “being coached” tapped into a familiar sporting paradigm--there was something to work toward, to win at. And it quickly caught on.

“It’s just amazing the variety of people who are coming into the business, repackaging themselves,” he says. From the very beginning, people who were most accustomed to counseling others, therapists among them, were drawn to coaching, “particularly at a time that they were losing their autonomy. It just made sense.”

Indeed, the rise of coaching neatly paralleled the rise of managed care’s influence in the lives of therapists.

“In the ‘80s, you kept hearing, ‘Managed care, it’s coming! It’s coming,”’ says Denning-Mailloux. And with it came salary cuts and a loss of autonomy. “What I hear from clinicians,” she says, “is there has got to be an easier way to make a difference with people, using their training.”

What struck some who were looking at the coaching model was that there were clearly ways to resolve quality-of-life issues that didn’t require a therapist’s couch.

“Coaching is an evolutionary step,” says Patrick Williams, a Colorado clinical psychologist and president and founder of the Institute for Life Coach Training (formerly Therapist University). “God bless therapy, but we’ve over-pathologized.... The proliferation of therapy has pathologized a whole generation.”

Williams, who has been a coach since 1993, is critical of what he sees as an inherent narrowness in thinking about counseling in general. “The problem with psychotherapy, a certain part of psychotherapy, is that they [think] they own the rights to behavioral changes. Encouragement, help, airing emotions can help. But psychotherapy does not own the ability to make changes.”

Williams was frustrated with both managed care and therapy itself. “I didn’t buy into diagnosing people,” he says, adding, as many therapist-cum-coaches do, “I was already ‘coach-like’ in my approach to therapy.” By the ‘90s, he had begun to explore executive coaching. He enrolled in Coach U in ’96. Although he found the training somewhat redundant (“As a psychologist I didn’t need eight weeks on how to listen,” he says), it shook up his old mode of thinking.

In ’98 he founded Therapist University to acknowledge the strengths that therapists brought to coaching--posting questions, listening, intuition--while also helping them develop business skills that would allow them to build a strong client base. Key to the training is helping care providers make the distinction between therapy’s inward focus and coaching’s broad external embrace. “Trained therapists are already experts at listening,” says Williams, but as a coach, “I’m not a shrink, I’m an enlarger. I’m enlarging your vision, enlarging your life.”

While “coach” is a designation that appears to neatly sidestep both the stigma and protracted drama of therapy, its open-ended job profile seems potentially problematic to some. What some therapists see as godsend, others decry as short-cut or “therapy without a license.” And as more clinicians enter coaching, it’s inevitable that some of the standards and expectations of their old profession will bleed into the new.

As a rule, coaches make clear that their role isn’t to “fix people” per se, but to move them into “higher functioning.” It’s an axiom in coach training that coaching is not therapy and that coaches are not to stand in for professionals when clients have problems that go beyond those of the “worried well.” But the perception that people need coaches to grow and succeed is troubling, say some, especially when coaches’ support comes at such a high price.

Coaching is “an industry that is built on people’s weaknesses, not their strengths,” worries Cathy Conheim, a La Jolla-based licensed clinical social worker and therapist. “It encourages the belief that we need something outside of ourselves to report to. In therapy you’re learning how to build emotional muscle. Coaching doesn’t encourage the tools to be self-regulating.”

What concerns her most are the hidden issues that a coach who is not professionally trained in the interactions of mind and body might stumble on. Therapists learn to quickly size up the verbal and nonverbal cues of those they see. But in coaching, she explains, particularly because of the phone, it’s difficult to assess what kind of support a person needs.

A person with bipolar tendencies might need structure, she says, “but a person who is just a healthy neurotic and not in touch with their feelings, I want to break down their barriers. The difference is very important. You don’t want to go asking someone who is psychologically unsound to do a lot of loosey-goosey stuff when they are just borderline anyway.”

Wayne Hart, a psychologist and coaching manager at the Center for Creative Leadership in San Diego, says that often the best clue that someone looking for assistance from a coach might be looking for help in the wrong place is lack of progress in coaching. “If there is anxiety or depression, or a personality disorder at threshold, coaching won’t work. The person doesn’t take action.”

But, adds Hart, “what a clinician would catch in a first session, a competent coach would pick up in a fourth,” which he believes is enough time to make a referral to a health-care professional.

Williams, however, cautions that choosing a coach, like choosing any other person who might have an influence over your life, requires common sense and care. “Just because I’m a therapist who is also a master certified coach, doesn’t make me better than a coach who is not.... Interview prospective coaches. Check them out. If a client is going be paying those fees, you’d better ask.”

Reeder, of the coaching federation, has seen increasing signs of coaching’s allure for therapists. And new, specially tailored seminars, courses and programs aimed exclusively at and packaged for therapists have begun convening in both the real and virtual world.

Clinicians are being advised to add “coaching techniques” to their practice or phraseology to their pass-out literature to help raise their profile and increase their client base. And even the American Assn. of Marriage and Family Therapists will offer coach training in the spring.

Therapists who decide to enter coaching are redefining both fields. Coaching, say some, might very well be better than therapy for tending to life’s dead-ends and stumbling blocks--leaving a job, starting a business, prioritizing work. “It’s trying to get from one trapeze to the other,” says Jeffery Spar, a Miami-based psychologist and coach. “For one moment you are suspended, exploring those places. Not in a frivolous way.” Most people are afraid to let go and be in that open, uncertain middle space. “And I don’t know that therapy is the only way to deal with those issues.”

Coach/therapists such as Spar are encouraged by the synergy, one practice informing the other. “One of the newer orientations of patient care--the psychology of possibility--is taking people of the highest level of functioning and moving them forward. And that may be an outgrowth of coaching.”

However, there is more than idle worry among therapists and their legal advisors, says Denning-Mailloux, about the close quarters coaching and therapy are keeping. No high-profile, big-ticket legal business has yet sprung up around suing coaches. But, she adds, “there is only a matter of time before people figure out that there is money to be made from therapists who are also coaches.” Though the ICF hasn’t been called into action in a legal matter, down the road, figures Reeder, coaches will become more vulnerable. Therapists have long been held to account for their effect on clients, and as coaches draw closer to therapy’s realm, it’s likely they will be too.

Reeder believes that as coaching programs proliferate, unified standards, credentials and even government licensing are needed to help to clarify the scope and intentions of the industry in general, and welcomes the trend.

But some coach/therapists such as Williams and Denning-Mailloux, refugees from battles with HMOs, want coaching to regulate itself and are wary of the government intervention that they entered coaching in part to escape.

For now, Spar says he will relish the chance to explore the best of both worlds, “I don’t want to stop being a therapist. But I like the flexibility of coaching ... getting up in the morning and knowing that I’m letting people see the passion and purpose in their lives, and knowing that I’m having an influence. I sometimes foresee when I have to retire,” he says, “but I may just hold on to coaching.”