Health and wellness coaching

1. Introduction

Version followed: the US National Board for Health & Wellness Coaching (NBHWC) standard, meaning the HWC Scope of Practice and the HWC Certifying Examination Content Outline 2026–2030. Session-by-session procedure follows the Vanderbilt Health Coaching Program (VHCP) model as published by Wolever & Weinand (2025), which the authors describe as aligned with NBHWC structure. The operational definition comes from Wolever et al. (2013). Other schools (for example Wellcoaches/Moore's Coaching Psychology Manual, the original Duke Integrative Health Coaching curriculum, NHS personalised-care health coaching) are not drawn on in primary form and are not followed here [uncertain].

What it is. Health and wellness coaching (HWC) is a professional field and a semi-structured model, not a single psychotherapy. Wolever et al. (2013) defined it from 284 studies as a patient-centred process grounded in behaviour-change theory. It combines client-determined goals, self-discovery and active learning, some content education, and accountability for behaviours, all within an ongoing relationship with a trained coach [source: Wolever et al. 2013, Duke Scholars abstract]. NBHWC describes coaches as helping clients use their own insight, strengths and resources to reach "self-determined health and wellness goals", acting as an "accountability partner, not director" [source: NBHWC Scope of Practice].

How change is thought to happen. Change comes from the client's own motivation and self-efficacy. The coach does not supply it. The coach uses motivational interviewing (MI), visioning, values and strengths work and mind–body practices to widen the felt gap between current and desired health. The client then turns that gap into small, self-chosen behavioural steps and tracks them. Repeated successful steps build confidence and habit [source: Wolever & Weinand 2025; NBHWC Content Outline §2, theories listed: neuroplasticity and habit formation, Transtheoretical Model, MI 4.0, goal-setting theory, self-efficacy, self-determination theory, growth mindset, positive psychology, appreciative inquiry].

For a psychotherapist. Using HWC means stepping into a different role with a narrower scope. NBHWC treats this as a dual role. You must disclose at the start which role you are in and document it [source: NBHWC Scope of Practice; ICF Code of Ethics 2025 cl. 3.7].

2. Framework

Format. One-to-one or group. In person, phone or video. Formats include long-term, brief ("laser"), virtual and incentivised [source: NBHWC Content Outline 1.5.2.2]. A VHCP programme typically runs 3–6 months, often fixed by the payer [source: Wolever & Weinand 2025].

Scope boundary. These are the rules that define the frame:

• NBHWC. Coaches do not diagnose or interpret medical data, prescribe or de-prescribe medication, recommend supplements, give nutrition consultation or meal plans, prescribe exercise, or advise as an expert. They do not provide psychological therapeutic interventions. NBHWC defines those as methods used by qualified professionals to remediate a diagnosed condition, and names CBT, EMDR, solution-focused therapy, DBT and IFS as examples. Coaches may share evidence-based information from nationally recognised authorities, and only when the client gives permission or asks. They support the client's healthcare-team plan [source: NBHWC Scope of Practice; Content Outline 4.2]. Coaches must refer for imminent danger, trauma treatment, mental-health treatment and other healthcare needs [source: Content Outline 4.2.2].
• ICF. Coaching focuses on visioning, success, the present and future, and generally serves well-functioning people. Therapy addresses psychopathology, healing and the past. The ICF compares the coach to an athletic trainer and the therapist to a sports-medicine doctor [source: Hullinger & DiGirolamo 2018, ICF]. The ICF Code (effective 1 April 2025) requires coaches to stay alert to signs that coaching no longer serves the client and to explore "a different coach, professional, or resource" (cl. 4.3). Coaches must work within their competence (cl. 5.1) and agree confidentiality limits in advance, including risk of danger to self or others (cl. 2.3) [source: ICF Code of Ethics].
• EMCC and AC (Global Code of Ethics). The code states that coaching is not counselling, psychotherapy or medical intervention, and members must respect those boundaries. Members refer clients to suitably qualified practitioners where appropriate. They encourage ending the engagement if "a different form of professional help" would serve the client better. They state confidentiality limits (illegality, danger to self or others) when contracting [source: EMCC Global Code of Ethics V4, 2021/2025; AC Code page].
• VHCP authors. HWC "does not involve the process of diagnosis nor treatment". Coaches can bring in provider recommendations, but they ask what the client thinks of them rather than imposing provider-set goals [source: Wolever & Weinand 2025].

3. Guiding principles

[source: NBHWC Content Outline §1, §3.3; Wolever & Weinand 2025; NBHWC Scope of Practice]

• Presence as foundation. Arrive calm and receptive. Ground yourself before each session.
• Client as expert on their own life. The client is resourceful and autonomous, so ask before you offer, and never set the goal yourself.
• Client-determined goals. VHCP goals are set by the client, not shared with the coach as in traditional MI. Provider recommendations become options the client weighs.
• Refrain from directing, advising or problem-solving. When you feel the pull to fix, turn it into an open question or a reflection.
• MI spirit (CAPE: compassion, acceptance, partnership, empowerment). Every exchange should leave the client more in charge.
• Unconditional positive regard, empathy, non-judgement, curiosity. Respond to lapses with curiosity about what happened, never with disappointment.
• Welcome the full emotional experience. Emotions are allowed in session. Persistent processing without movement toward action is a referral signal (see §5).
• Strengths-based and appreciative. Name the client's successes, values and strengths out loud and refer back to them.
• Cultural humility and attention to power. Ask preferred names and pronouns. Notice power and privilege imbalances. Repair microaggressions and other breaches promptly.
• Whole person. Link the focus behaviour to the other wellness dimensions: social, physical, intellectual, occupational, financial, emotional, environmental and spiritual.
• Structural and social determinants are real. Adapt plans to housing, money, access and literacy. Recognise barriers the client cannot change, and don't treat them as motivation problems.
• Small, achievable steps build self-efficacy. Size each step so that confidence is about 7/10 or higher.
• Client-owned accountability. The client chooses how to self-monitor, how to be held accountable and how to make contact.
• Information only with permission and within scope. Use Ask-Offer-Ask. Cite nationally recognised sources. Never give meal plans, exercise prescriptions or medication advice.
• Know your limits and refer. Screen for fit at the start, and keep monitoring for referral signs throughout.
• Invite feedback. Build feedback mechanisms into the agreement and use them every session.
• Integrity and transparency. Disclose conflicts of interest, such as product sales, and any dual role. Represent your credentials accurately.
• Confidentiality with stated limits. Agree the exceptions in writing at contracting, and handle data securely. NBHWC adds that client data must not be put into generative AI and that any use of AI must be disclosed (Content Outline 4.3.8, 4.4.1.5).

4. Intervention inventory

Unless tagged otherwise, items come from the NBHWC Content Outline 2026–2030 (numbers given) and Wolever & Weinand (2025, VHCP). The step sequences combine what those sources list. Where a source names a tool without giving its procedure, the steps are [synthesis]. All example language is illustrative.

4.1 Session preparation and coach grounding

• Purpose: to arrive present, without carrying in assumptions from the client's notes or chart.
• Steps: (1) Review the client's materials, such as intake, prior action steps and any provider notes, looking for strengths. Keep in mind that the record shows only part of the client's culture and life history. (2) Check logistics, confidentiality, access needs and distractions. (3) Do a brief mindfulness or grounding practice yourself just before the session [source: Content Outline 1.4; Wolever & Weinand 2025, where coaches learn mindfulness first to self-regulate].
• Example language: none, as this step is internal.
• Watch for: pre-formed plans for the client. Drop them before the session starts.

4.2 Establishing the coaching foundation and appropriateness check

• Purpose: to make sure coaching, rather than treatment, is the right service now.
• Steps: (1) Explain coaching in plain language: the client sets the goals, the coach does not diagnose, treat or prescribe, and sessions focus on present and future action. (2) Explore why the client wants coaching and why now. (3) Screen for referral indicators (see §5.1). Ask directly about current mental-health or medical care and any risk [synthesis on the direct questions]. (4) Decide together whether you fit as coach and client. (5) Agree how the client will give you feedback [source: Content Outline 1.5.1].
• Example language: "In coaching you set the direction and I help you think and plan. I won't diagnose or treat anything, and I'll tell you if something looks like it needs a different kind of help. What made now the time to start?" (illustrative)
• Watch for: a client who really wants treatment for low mood, trauma or disordered eating. If so, refer first (§4.25).

4.3 Co-creating the coaching agreement

• Purpose: to set a clear frame that protects both client and coach.
• Steps: Agree and document the following [source: Content Outline 1.5.2; ICF Code cl. 1.1, 2.3; EMCC/AC Global Code §2–3; NBHWC Scope]:
  • logistics: fees, scheduling, cancellation, duration, and whether others such as family or a care team are involved;
  • format;
  • roles, responsibilities and expectations;
  • confidentiality and its limits (danger to self or others, legal requirements);
  • data handling and accessibility;
  • your role, if you also hold a clinical licence (dual-role disclosure).
  Then ask the client to say back what they have agreed to.
• Example language: "What we discuss stays between us. The exceptions are if I believe you or someone else is in danger, or the law requires me to share. Can you tell me in your own words how you understand our arrangement?" (illustrative)
• Watch for: confusion between the coaching role and the therapy role. Re-state the frame whenever the client treats sessions as therapy.

4.4 Wheel of Health (whole-person self-assessment)

• Purpose: to help the client survey all life domains and find where their energy for change is.
• Steps: (1) The client rates current satisfaction and desired satisfaction (1–10) in each of the nine VHCP domains. (2) For each domain, the client notes their readiness to change. (3) Explore the gaps the client finds meaningful, including how thoughts, emotions, body sensations and behaviours link to daily habits [source: Wolever & Weinand 2025]. NBHWC lists Wellness Wheels and the Personal Health Inventory as equivalent tools [source: Content Outline 3.1.1]. The nine domain names were not given in the source cited [uncertain]. Use the domain set from the tool you have licensed or adopted.
• Example language: "Looking at your wheel, which gap surprises you? Where do you feel most ready to make a change?" (illustrative)
• Watch for: rating every domain low together with hopelessness. This can point to depression rather than a coaching focus (§5.1).

4.5 Guided visualization of default and optimal health (visioning)

• Purpose: to make the desired future vivid and personally meaningful, and so widen the gap between current and desired states.
• Steps: (1) Use Ask-Offer-Ask: ask permission, explain the exercise, and offer it as a choice. (2) Guide the client to imagine their default future, meaning where things go if nothing changes. (3) Guide them to imagine their optimal health and wellbeing, using sensory and bodily detail. (4) Return to the room. Use open questions and reflections to explore the vision, the values beneath it and the strengths it calls on [source: Wolever & Weinand 2025; Content Outline 1.5.3, 3.1.5, 3.3.3].
• Example language: "If you'd like, close your eyes or soften your gaze. Picture yourself a year from now, at your healthiest. Where are you? What do you notice in your body? What are you doing that you can't do now?" (illustrative)
• Watch for: distress during imagery, such as intrusive memories or dissociation. Stop, ground the client, and consider referral. Imagery is optional, and an eyes-open conversation about the vision works too [synthesis].

4.6 Values and strengths exploration

• Purpose: to anchor change in what matters to the client and in abilities they already have.
• Steps: (1) Use a values exercise or survey and a strengths survey. (2) Name the values and strengths you hear. (3) Ask how each strength could support the chosen change [source: Content Outline 3.1.3–3.1.4, 3.5.3; Wolever & Weinand 2025]. Specific survey instruments are not named in the sources. Use validated tools you are licensed to use [uncertain].
• Example language: "You got through that hard year by being organised and asking for help. How could those same strengths help with this?" (illustrative)
• Watch for: the client being unable to name any strength. Offer affirmations based on what you have observed.

4.7 Choosing a focus area with the importance ruler

• Steps: (1) The client picks one domain from the Wheel or vision. (2) Ask how important the change is, from 0 to 10. (3) Follow up: "Why that number and not a lower one?" This draws out the client's own reasons [source: Wolever & Weinand 2025; Content Outline 3.1.7]. The "why not lower" follow-up is standard MI practice, applied here [synthesis].
• Example language: "On a scale of 0 to 10, how important is getting more rest to you right now? … A 6. What puts it at 6 rather than 3?" (illustrative)
• Watch for: low importance. Explore other domains rather than pushing this one.

4.8 Long-term "umbrella goal"

• Purpose: to give the coaching period a direction the client controls.
• Steps: (1) Translate the vision into a SMART goal for the length of the programme. (2) Frame it as a behaviour within the client's control, not an outcome such as a lab value or body measure. (3) Prefer approach goals (doing something) over avoidance goals (stopping something) [source: Wolever & Weinand 2025; Content Outline 3.9.1, 3.9.3]. Do not supply numeric diet, weight or exercise targets yourself. Any targets come from the client or their clinicians [source: NBHWC Scope].
• Example language: "How could you say that as something you'll do, that's fully in your hands?" (illustrative)
• Watch for: outcome-only goals. Ask: "What would you be doing differently that would get you there?"

4.9 Action-step planning

• Purpose: to set a concrete, achievable step for the next 1–2 weeks.
• Steps: (1) The client names the step: what, when, where and how often. (2) Identify supports. (3) Anticipate barriers and make a contingency ("if… then…") plan. (4) The client chooses how to track the step. (5) Check confidence (§4.10). Steps can be cognitive or mindset changes as well as actions [source: Wolever & Weinand 2025; Content Outline 3.9.2–3.9.9].
• Example language: "What might get in the way? … And if that happens, what will you do instead?" (illustrative)
• Watch for: steps the client sets to please you. Ask whose idea the step is.

4.10 Confidence ruler

• Steps: (1) Ask how confident the client is, 1–10, that they will do the step. (2) If the answer is below 7, explore what would raise it, or shrink or modify the step until confidence reaches 7 or above [source: Wolever & Weinand 2025]. (3) Ask what makes it that number rather than lower, to bring out the client's own abilities [synthesis].
• Example language: "You're at 5. What would make it a 7? A smaller version, someone to do it with, a different time?" (illustrative)

4.11 Check-in on prior action steps

• Steps: (1) Open question about how the client is now. (2) Optionally, a brief mindfulness practice (§4.17). (3) Set the agenda together. (4) Review the step, drawing out successes first, then lessons. (5) Reframe barriers as information [source: Wolever & Weinand 2025; Content Outline 1.6.1–1.6.2].
• Example language: "What went well with the evening walks, even partly? … And what did you learn from the nights it didn't happen?" (illustrative)
• Watch for: shame after lapses. Respond with self-compassion work (§4.18).

4.12 VHC Funnel (core of routine sessions)

• Purpose: to bring out desire, ability, reasons, need, commitment and activation within about 12–18 minutes of focused time.
• Steps:
  1. Importance: why the topic matters, linked to values.
  2. Visioning: how life would be different, with sensory and bodily detail.
  3. Self-efficacy: past successes and strengths, linked to this change.
  4. Planning: narrow to a client-set step, with supports and barriers (§4.9–4.10).
  In VHCP the client chooses the session topic, which may or may not relate to the umbrella goal [source: Wolever & Weinand 2025]. NBHWC frames the same flow as what (topic), why (what matters most) and how (steps aligned with vision and values) [source: Content Outline 1.6.3–1.6.5].
• Example language: "Why does this matter to you now? … Imagine it's going well: what's different on a Tuesday? … When have you pulled off something like this before? … So what's one step for this week?" (illustrative)

4.13 IVA Funnel (brief clinical encounters, under 5 minutes)

• Purpose: a coaching moment inside a medical or therapy visit.
• Steps: (1) Importance: elicit one behaviour the person is ready to change and why it matters. (2) Visioning: imagine the benefits. (3) Activation: action-oriented questions toward one small, specific step [source: Wolever & Weinand 2025].
• Example language: "Of the things we've talked about, which one feels most doable? What would be better if you did it? What's the smallest first step?" (illustrative)

4.14 OARS and reflective listening

• Purpose: to make the client feel heard and to steer toward change. OARS stands for open questions, affirmations, reflections and summaries.
• Steps: Use the following throughout the session [source: Content Outline 3.2; Wolever & Weinand 2025]:
  • Active listening, including nonverbal cues and what is left unsaid.
  • Silence and pauses.
  • Open questions in preference to closed ones.
  • Affirmations, acknowledgements and validations.
  • Simple reflections and paraphrases.
  • Complex reflections: double-sided, metaphor, meaning, emotion.
  • Summaries, especially at transitions.
• Example language: double-sided reflection: "Part of you is tired of feeling run down, and part of you dreads giving up the late nights that are your only time to yourself." (illustrative)
• Watch for: reflections that drift into interpretation of the past. In coaching, keep reflections on present experience and future action [synthesis].

4.15 Cultivating change talk, softening sustain talk, responding to discord

• Steps:
  • Draw out preparatory change talk with DARN: desire, ability, reasons, need.
  • Then mobilising talk: commitment and activation.
  • Respond to sustain talk with reflections rather than counter-arguments.
  • Treat discord as a relationship signal. Reflect it, emphasise the client's autonomy and adjust [source: Content Outline 2.3, 3.2.7; Wolever & Weinand 2025, MI 4.0 tasks: engaging, focusing, evoking, planning].
• Example language: sustain talk, softened: "It really doesn't feel like the right time." Discord: "It sounds like I've been pushing. You're the one who decides whether this is the focus at all." (illustrative)

4.16 Ask-Offer-Ask (sharing information within scope)

• Purpose: to give content education and to bring in provider recommendations without taking over the agenda.
• Steps: (1) Ask what the client already knows and whether they want information. (2) Offer brief, neutral information from nationally recognised authorities (NBHWC names the CDC, HHS, NIH and Healthy People 2030), or remind them of their clinician's recommendation. (3) Ask what they make of it and how, if at all, they want to use it [source: Content Outline 3.2.7.4, 4.2.1; NBHWC Scope; Wolever & Weinand 2025]. Never create meal plans, exercise prescriptions, supplement or medication advice. Send those questions to the client's clinician or a registered dietitian [source: NBHWC Scope].
• Example language: "Would it help to hear what the national sleep guidance says in general? … How does that fit with your situation?" (illustrative)

4.17 Brief mindfulness at session start

• Steps: (1) Ask-Offer-Ask to invite a short practice, always as a choice. (2) Guide a minute or two of breath or body awareness. (3) Ask what the client noticed, then set the agenda [source: Wolever & Weinand 2025; Content Outline 3.1.8]. The length is [synthesis].
• Watch for: anxiety or dissociation during inward focus, especially in trauma survivors. Offer eyes-open, external-focus options or skip the practice [synthesis].

4.18 Awareness and perspective-shift tools

• Purpose: to address the thoughts and emotions that block a behaviour. This is done within coaching scope, not as cognitive therapy for a disorder.
• Steps (menu):
  • Bring self-talk into awareness.
  • Acknowledge self-defeating thoughts and limiting beliefs.
  • Explore patterns: triggers, thoughts, emotions, sensations, environment, culture.
  • Invite reframes and perspective shifts.
  • Amplify insights.
  • Help the client name emotions.
  • Foster self-compassion and self-acceptance.
  • Draw out positive emotions such as gratitude.
  • Nurture optimism, persistence and resilience.
  [source: Content Outline 3.4; mindset listed at 2.7]
• Example language: "What did you tell yourself when you skipped it? … Would you say that to a friend in the same spot?" (illustrative)
• Watch for: entrenched negative beliefs tied to trauma, or patterns that meet referral criteria. That is psychotherapy territory under NBHWC's definition, so refer rather than treat (§5.1).

4.19 Self-efficacy building

• Steps (menu):
  • Identify role models (vicarious learning).
  • Offer affirmations.
  • Plan how to use strengths.
  • Set achievable steps.
  • Have the client self-assess and name their progress.
  • Treat identity and lived experience as central to decisions.
  • Weigh options for short- and long-term benefit.
  [source: Content Outline 3.5]
• Example language: "Who do you know who has made a change like this? What did they do that you could borrow?" (illustrative)

4.20 Expanding and narrowing the conversation

• Expanding: open and appreciative questions, evocative questions, metaphors built from the client's own words, links to other life dimensions, broader possibilities, and recalling what the client said earlier.
• Narrowing: interrupt and redirect skilfully, bottom-line (ask for the essence), and ask the client to summarise [source: Content Outline 3.6–3.7, 3.10].
• Example language: "Can I pause you? Of everything you've said, what's the heart of it for today?" (illustrative)

4.21 Building support and adapting to determinants of health

• Steps:
  • Map social, family and professional supports.
  • Identify community resources.
  • Make structural and environmental changes, such as restructuring the home or work environment step by step.
  • Name barriers the client cannot change.
  • Adjust for health literacy and numeracy.
  [source: Content Outline 3.8, 5.2.3, 5.5–5.6]
• Example language: "What in your kitchen, schedule or neighbourhood makes this easier or harder? Which of those can you change, and which do we need to plan around?" (illustrative)

4.22 Self-monitoring and client-owned accountability

• Steps: The client chooses the tracking method (journal, app, wearable, check-in message) and how they want to be held accountable. Honour their preferences on contact mode. Get documented consent before collecting any data [source: Content Outline 3.1.9, 3.3.4, 3.9.7, 4.4.1].
• Watch for: tracking that turns obsessive, for example around food or weight. This is an eating-disorder warning sign (§5.1).

4.23 Session closing

• Steps: (1) The client summarises their next steps. (2) The client reflects on what they learned and their key takeaways. (3) Affirm and acknowledge the client. (4) Set the next contact [source: Content Outline 1.6.6; Wolever & Weinand 2025].
• Example language: "What are you taking away today? … And your plan until we meet?" (illustrative)

4.24 Programme closure and maintenance plan

• Steps:
  • The client states their progress, lessons and growth, including what they learned about how they change.
  • The client plans how to celebrate.
  • Affirm the progress.
  • Co-create a maintenance plan that includes "yellow flags": early signs that more support is needed.
  • Summarise resources and share them with permission.
  [source: Content Outline 1.7; Wolever & Weinand 2025]
• Example language: "What would be the first sign you're sliding back? What will you do when you notice it?" (illustrative)

4.25 Referral conversation and crisis procedure

• Purpose: to move the client to clinical care when they need it.
• Steps: These follow the ICF guidelines [source: Hullinger & DiGirolamo 2018, ICF]:
  1. Meet privately, at an unhurried time.
  2. Set a calm, caring and hopeful tone.
  3. Name the specific signs you have observed.
  4. Ask open questions and listen.
  5. Allow silence.
  6. Ask how the client feels about the suggestion.
  7. Restate your concern and care.
  8. Offer specific resources from a pre-built list of clinicians, with their specialties.
  9. Keep the topic open for later.
  10. Offer practical help, such as letting the client book the appointment from your office.
  Expect the client to hesitate. Normalise mental-health care and address stigma, cultural and access barriers (the guidelines suggest a heart-specialist analogy). Respect the client's choice unless there is risk of harm. If the issue blocks progress, suggest pausing coaching until the client is in therapy. Coaching can continue alongside therapy if the client functions day to day and is still making progress. Revisit the agreement to clarify what each service covers [source: ICF 2018].
• Crisis: If there is imminent danger, call emergency services. If self-harm or harm to others is possible, stay with the person until help arrives. Ask about access to means and arrange safe storage with someone else. Agree who to notify. Use crisis lines. Breach confidentiality only for serious risk, within the limits agreed at contracting [source: ICF 2018; ICF Code cl. 2.3; EMCC/AC Global Code §3]. For a licensed psychotherapist, your own professional duties of risk assessment and duty to warn or protect still apply in the coaching role [synthesis].
• Example language: "I've noticed over the last few sessions that you've been sleeping very little and said things feel pointless. I care about how you're doing, and I think talking with a mental-health professional could really help. How does that sound to you?" (illustrative)

4.26 Dual-role disclosure (clinicians who also coach)

• Steps: (1) At the start, state which role you are in. (2) Name any conflicts of interest, for example product sales or a prior therapy relationship. (3) Document the role. (4) Keep clear boundaries [source: NBHWC Scope; ICF Code cl. 3.7]. Whether you may switch to therapy with the same client mid-contract depends on your licensing board and service setting. The sources cited do not settle this [uncertain]. A conservative default is to refer to a separate clinician or to re-contract formally [synthesis].

5. Handling problems

5.1 Signs a coachee needs referral to clinical care

Core test (ICF). Does the issue interfere with daily functioning (self-care, work, home, leisure)? Weigh how long it has lasted, how often it happens and how intense it is. Look for a cluster of signs, because one sign alone is not enough [source: Hullinger & DiGirolamo 2018, ICF]. NBHWC requires referral for imminent danger, trauma treatment, mental-health treatment and other healthcare needs [source: Content Outline 4.2.2].

Signs inside coaching [source: ICF 2018]:

• no progress after a reasonable time;
• unresolved past issues that keep coming back;
• ongoing processing of feelings with no movement toward action;
• self-defeating behaviour that blocks every plan;
• the client is stuck on a past incident, frames themselves as a victim, or shows ongoing effects of trauma.

Signs of distress [source: ICF 2018]:

• marked change in mood (irritability, anger, anxiety, sadness);
• falling performance at work or school;
• withdrawal from people and activities;
• changes in weight, appearance or hygiene;
• sleep disturbance.

Condition-specific patterns the ICF lists (for recognition, not diagnosis) [source: ICF 2018]:

• Depression: sadness for more than two weeks, with loss of interest, worthlessness or guilt, or thoughts of death.
• Anxiety: excessive worry most days, with physical tension.
• Disordered eating: obsessive thoughts about food; cutting out food groups or organising life around diet without a medical reason.
• Trauma: intrusions, nightmares or flashbacks; avoidance; hyperarousal; detachment.
• Substance use: rising tolerance, hiding use, neglecting obligations, feeling unable to stop.
• Suicidal ideation: hopelessness, no reason to live, giving away possessions, seeking means, reckless behaviour.
• Thought disorder: paranoia, delusions, hallucinations, incoherent speech.

Health-coaching-specific triggers:

• Signs of an acute medical emergency, such as stroke (FAST) or heart-attack signs, which NBHWC expects coaches to recognise. Call emergency services [source: Content Outline 5.3.1.1].
• Symptoms suggesting a sleep disorder such as apnoea, or substance use, which NBHWC lists with "when to refer" [source: Content Outline 5.3.3–5.3.4].
• Any new or worsening physical symptom, or a question about medication. Route these to the client's clinician [synthesis, consistent with NBHWC Scope].
• Food, weight or exercise goals that become rigid or compulsive. Pause that focus and refer [synthesis].

Signs in yourself (ICF self-check). Consult a supervisor or clinician if you feel responsible for the client, under pressure to solve their problems, stressed or anxious about them, out of your depth, as if they depend on you too much, or as if you have failed them [source: ICF 2018].

The referral and crisis steps are in §4.25. Formal mental-health referral guidelines for NBC-HWCs (Voss et al. 2026), covering screening, referral language and crisis procedures, exist, but only the abstract is drawn on [uncertain].

5.2 Stuck clients (repeated non-completion of steps)

• Response: Check confidence on the step. If it is below 7, shrink or change the step [source: Wolever & Weinand 2025]. Go back to importance and vision (VHC Funnel), and check whether the focus is still the client's own or was adopted from a provider. Explore barriers in the environment and determinants of health before treating the problem as motivational [source: Content Outline 3.8.4, 3.9.9].
• If the client stays stuck after a reasonable time, apply the ICF progress indicators in §5.1 [source: ICF 2018].
• Re-contract openly: "Is this still the right focus, and is coaching the right help right now?" [synthesis].

5.3 Resistance, sustain talk and discord

• Response: Treat discord as a signal that you have moved ahead of the client. Reflect it, stress their autonomy, ask permission before offering anything, and hand the agenda back [source: Content Outline 3.2.7.3; Wolever & Weinand 2025].
• Respond to sustain talk with reflections rather than arguments. A double-sided reflection that ends on the client's own change talk often works [synthesis from MI practice].

5.4 Overwhelm

• Response: Narrow to one domain and one small step, and use bottom-lining [source: Content Outline 3.7]. Offer a brief grounding or mindfulness practice as a choice [source: Wolever & Weinand 2025].
• Acknowledge non-modifiable stressors [source: Content Outline 3.8.4].
• If overwhelm reflects acute distress, panic, dissociation or trauma activation, stop the coaching task, ground the client, and assess for referral [synthesis].

5.5 Non-adherence and lapses

• Response: Draw out successes first, then lessons. Frame lapses as data [source: Wolever & Weinand 2025]. Build self-compassion [source: Content Outline 3.4.7].
• Revisit the contingency plan and the tracking method the client chose. Normalise lapses during habit formation [synthesis].
• Never shame the client, and never escalate to directives [source: Content Outline 1.2.3].

5.6 Ruptures

• Response: Attune to discord, breaches of trust and microaggressions. Name what happened, take responsibility for your part, invite feedback, and repair [source: Content Outline 1.1.9, 1.3.2.7]. Check for power dynamics, such as a referral that felt mandated by a doctor or employer [source: Content Outline 1.3.2.6].
• If the relationship can't be repaired, offer a different coach or resource [source: ICF Code cl. 4.3].

5.7 Modality-specific difficulties

• The client asks for a meal plan, exercise programme, supplement or medication advice. Explain your scope. Offer general information from national authorities only with permission. Refer to their physician or a registered dietitian, then help the client plan how to act on that professional's advice [source: NBHWC Scope].
• A provider-set goal conflicts with the client's own goal. Present the provider's recommendation through Ask-Offer-Ask, explore what the client thinks of it, and let the client decide [source: Wolever & Weinand 2025]. With consent, encourage the client to discuss the conflict with the provider [synthesis].
• Weight- or appearance-focused goals in a client with disordered-eating signs. Shift to non-weight behavioural goals the client endorses, and refer [synthesis; signs per ICF 2018].
• Grief, anger or loss of identity after a diagnosis or disability. Mindset shifts in the presence of illness are within scope [source: Content Outline 5.2.8.3]. Persistent depression or an inability to imagine the future meets the ICF referral threshold [source: ICF 2018].
• Fixed programme length set by the payer. Plan closure and the maintenance plan from the first session [source: Wolever & Weinand 2025 on payer-set duration; the planning is synthesis].
• Low health literacy or numeracy. Use plain language, teach-back and visual tracking [source: Content Outline 3.8.5, 5.7; specific methods are synthesis].
• Dependence on the coach. Move accountability back to the client's own systems and supports, and bring closure forward [source: ICF 2018 self-check; Content Outline 3.9.7].
• The psychotherapist-coach drifting into therapy. This includes interpreting the past, working through trauma, or using CBT, EMDR or IFS techniques in a coaching contract. Stop and re-contract openly as therapy, under your licence and with documentation, or refer [source: NBHWC Scope; ICF Code cl. 3.7; the re-contracting route is synthesis].
• Distress during guided imagery or mindfulness. Stop, open the eyes, orient the client to the room, and offer non-imagery alternatives. Never use imagery to explore past events [synthesis].
• Data and technology. Keep client data off generative-AI tools and non-secure platforms, and disclose any use of AI [source: Content Outline 4.3.8, 4.4.1].

Sources

Sources:

• NBHWC Health & Wellness Coach Scope of Practice (PDF)
• NBHWC HWC Certifying Examination Content Outline 2026–2030 (PDF)
• Wolever & Weinand (2025), Integrating mind-body processes and motivational interviewing in health coaching, Frontiers in Psychology 16:1478525
• Wolever et al. (2013), A systematic review of the literature on health and wellness coaching, Glob Adv Health Med 2(4):38–57 (Duke Scholars abstract)
• Hullinger & DiGirolamo (2018), Referring a Client to Therapy: A Set of Guidelines, International Coaching Federation (PDF)
• ICF Code of Ethics (effective 1 April 2025)
• EMCC Global Code of Ethics V4 (June 2021 / December 2025) (PDF)
• Association for Coaching, Global Code of Ethics page
• Voss, O'Neill, Austin & Kreitzer (2026), Mental Health Referrals in Health Coaching: Guidelines for Safe, Ethical Practice (abstract only; DOI 10.1177/15598276261464952)

Further reading (not drawn on) [uncertain]:

• Miller, W. R., & Rollnick, S. (2023). Motivational Interviewing: Helping People Change and Grow (4th ed.). Guilford. This is the MI 4.0 that NBHWC references. The MI content here comes only from the sources listed above.
• Moore, M., Jackson, E., & Tschannen-Moran, B. Coaching Psychology Manual (Wellcoaches). Named as an alternative version and not followed.